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Evidence Base Medicine Newborn and Child Dominique Biarent Hôpital Universitaire des Enfants Urgences et Soins Intensifs http://www.c2005.org/presenter.jhtml?identifier=3022512 Your Guide to the 2005 International CoSTR Conference

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slide1

Evidence Base Medicine

Newborn and Child

Dominique Biarent

Hôpital Universitaire des Enfants

Urgences et Soins Intensifs

slide2

http://www.c2005.org/presenter.jhtml?identifier=3022512

Your Guide to the 2005 International CoSTR Conference

What is the purpose of the evidence evaluation process?The endpointof this process is the preparation of the International Consensus on CPR and ECC Science with Treatment Recommendations.

Consensus on Sciences and Treatment Recommendations

slide3

What is the purpose of the International CoSTR Conference?

ILCOR is conducting systematic reviews and updates of scientific evidence supporting ECC treatment recommendations. 

More than 300 CPR and ECC scientific topics will undergo evidence-based review 

This process represents the most comprehensive, systematic review of the resuscitation literature to date

slide4

Who's in charge?ILCOR - the International Liaison Committee on Resuscitation. 

includes 7 international resuscitation organizations

American Heart Association (AHA), 

European Resuscitation Council (ERC), 

Heart and Stroke Foundation of Canada (HSFC),

Resuscitation Council of Southern Africa (RCSA),

Australia and New Zealand Council on Resuscitation (ANZCOR),

InterAmerican Heart Foundation (IAHF).

Japan Resuscitation Council JRC : international observer to ILCOR.  

China (Ministry of Health) : international observer to the C2005 Conference. 

slide5
C2005 Evidence Evaluation Worksheets« Vasopressine leads to better outcome from pediatric cardiac arrest than epinephrine »
search strategy
Search Strategy
  • Vasopressin and cardiac arrest, children, ventricular fibrillation , resuscitation, asystole and children (MeSH term and textwords)
  • Pubmed 244 hits (19 Aug 2004)
  • Embase141 hits (19 Aug 2004)
  • Cochrane Library 1 hit (15 Aug 2004)
  • Update 24 Jan 2005 : 1 hit
slide10

Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.

  • LOE1 excellent RCT (intention to treat)
  • 1189 patients (no children)
  • Similar rate of survival to hospital admission for VF /PEA
  • Better survival for asystolic patients treated with vasopressin
  • In absence of ROSC with study drug, additional epinephrine improved survival in VP group not in EPI group
slide12

Voelckel WG, Lurie KG, McKnite S, et al. Comparison of epinephrine and vasopressin in a pediatric porcine model of asphyxial cardiac arrest. Crit Care Med 2000;28(12):3777-83.

  • Paediatric piglet model of asphyxial arrest
  • Epi or VP+Epi : higher myocardial BF
  • VP+Epi : higher cerebral BF
  • ROSC Epi 6/6* VP+Epi 5/6 VP 1/6
  • Limitation : use of high dose Epi (200 mcg/kg)
slide13

Voelckel WG, Lurie KG, McKnite S, et al. Effects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation. Crit Care Med 2002;30(5):957-62.

  • Paediatric piglet model of prolonged VF (8 min + 20 min CPR),
  • Combination VP (0.8 IU/kg) +Epi (45 g/kg) : higher left ventricular myocardial blood flow than VP or Epi alone
  • VP+Epi and VP alone : higher cerebral blood flow than Epi alone
  • ROSC ns VP + Epi 6/6 VP5/6 Epi 2/6.
slide14

Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation 2002;52(2):149-56.

    • 6 long lasting CA in 4 children after > 2 doses adrenaline
    • VP as rescue therapy
    • 3 ROSC (>1h)
    • 1 withdrawal therapy (>24 h)
    • 1 survivor
high dose versus low dose adrenaline
Author A

« High dose of adrenaline is harmful in children with in-hospital and out-of-hospital cardiac arrest »

Search strategies

209 articles excluded

40 articles analysed : 25 human and 15 animal model studies

Author B

« The recommended resuscitation dose of adrenaline for children (0.01 mg/kg) should be increased

Search strategies

Age less than 18 years

5 articles met full criteria

High dose versus low dose adrenaline
refractory ca is 2 doses of adrenaline
Refractory CA is > 2 doses of adrenaline
  • Goetting MG, Paradis NA. High dose epinephrine in refractory pediatric cardiac arrest. Crit Care Med. 1989;17:1258-62
  • 7 children received 0.2 mg/kg adre : 6 ROSC Compared to 20 historic controls (SDE): no ROSC
  • LOE 5 (fair)
  • Goetting MG, Paradis NA. High-dose epinephrine improves outcome from pediatric cardiac arrest. Ann Emerg Med. 1991;20:22-6.
  • Prospective intervention group versus historic control group (20 in each). HDE : 14 ROSC (70%), 8 long term survival, 3 intact
  • LOE 3
compression ventilation ratio
Author A

A universal compression-ventilation ratio should be used for infants and children irrespective of their age, etiology of arrest and number of rescuers

Search strategies

9 articles

Author B

Scientific evidence supports the superiority of a 5:1 CV ratio in children rather than the 15:2 CV ratio recommended for adults

Search strategies

20 articles used for discussion

9 articles in grid

Compression / Ventilation Ratio
in children
In children
  • Metabolic rates, CO2 production, ventilatory needs are higher in the non-arrest setting
  • Pediatric CA are precipitated by asphyxia or shock
  • In-hospital HCP are accustomed to a 5:1 rather than 15:2
  • time to BLS in asphyxial CA vs Time to defibrillation in VF are crucial
slide21
Rescue breathing is critically important for asphyxial arrest (inadequate O2 content and high CO2 in the lungs at the time of CA) but not necessary for VF
  • VF has a normal O2 / CO2 content in lungs and hyperventilation is deleterious
  • BLS not necessary fort short duration VF
  • BLS crucial for prolonged duration VF
evidence of science
Evidence Of Science
  • Manikin studies or animal studies (LOE 6)
  • Mathematical model (LOE 6)
slide23
Berg RA, Sanders AB et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for VF cardiac arrest. Circ 2001;104:2465-2470
  • Interrupting CC for rescue breathing decreases mean coronary perfusion, LV blood flow & number of compression in swine.
slide24
Dorph E, Wik L, Steen PA. Effectiveness of ventilation-compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation. Resuscitation. 2002;54:259-64
  • 1 lay rescuer – child sized manikin – 2 ratios 5:1 or 15:2
  • Same minute ventilation; Better compression with 15:2
slide25

Kinney SB, Tibballs J. An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression–ventilation ratios in manikin-simulated paediatric resuscitation. Resuscitation 2000;43:115-120.

slide26

Mean number of correct compression

J. L. Greingor. Quality of cardiac massage with ratio compression–ventilation 5/1 and 15/2.

Resuscitation 2002; 55:263-267

slide27

Babbs CF, Nadkarni V. Optimizing chest compression to rescue ventilation ratios during one-rescuer CPR by professionals and lay persons: children are not just little adults. Resuscitation 2004;61:173-81.

Optimum C/V ratios in pediatric basic life support

5 + AGE for Pro

5 + AGE/2 for LAY

slide28

DO2

DO2

Blood flow

Blood flow

Alv O2

Alv O2

  • Oxygen delivery function of C/V ratio
  • professionally trained rescuers (2 rescue breaths in 5 s)
  • lay rescuers, (2 rescue breaths in 16 s)

Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical conditions: a physiological and mathematical analysis. Resuscitation. 2002 Aug;54(2):147-57.

for 10 000 simulations
For 10 000 simulations

OPTIMAL RATIO between 30:2 and 50:2

slide31
Simplicity of teaching is crucial
  • Do we need an universal ratio?
biphasic defibrillation
Biphasic defibrillation

Number of shocks that failed to terminate the initial VF episode for monophasic weight-based and attenuated adult biphasic shocks in the 4, 14 and 24 kg weight categories. *P<0.01.

rosc and 4 24 h survival
ROSC and 4 & 24 h survival

Berg RA, Chapman FW et al Attenuated adult biphasic shocks compared with weight-based monophasic shocks in a swine model of prolonged pediatric ventricular fibrillation.Resuscitation 2004, 61:189-197

automated external defibrillator aed
Automated External Defibrillator (AED)
  • Evaluates the victim’s ECG
  • Determines if a “shockable” rhythm is present
  • Charges the “appropriate” dose
  • When activated by operator, delivers a shock
  • Provides synthetised voice prompts to assist the operator
aed in children
AED in children?
  • Experience limited
  • Recommended (Class IIb) for children older than 1 year in the pre-hospital setting (circulation 2003)
  • Remember:
    • Most arrests in children are respiratory in origin
    • The most frequent arrest rhythms are Asystole and PEA
    • Prompt defibrillation is the definitive treatment for VF and pulseless VT
    • Basic life support sequence
conclusion
Conclusion
  • Ongoing process
  • Evidence of science
  • Guidelines
  • Courses
  • Evidence Based Medicine