Rationale for the Current Paediatric Resuscitation Guidelines
Download
1 / 41

Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) - PowerPoint PPT Presentation


  • 293 Views
  • Updated On :

Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) Evidence? Janssens L, Altman S, Rogers PA. Vet Rec;105(12):273-6. Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK)' - jana


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Slide1 l.jpg

Rationale for the Current Paediatric Resuscitation Guidelines

Bob Bingham RC (UK)

Paediatric Anaesthesia Study Day


Evidence janssens l altman s rogers pa vet rec 105 12 273 6 l.jpg
Evidence? GuidelinesJanssens L, Altman S, Rogers PA.Vet Rec;105(12):273-6.

Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum.

“In seven cases of anaesthetic apnoea with concurrent cardiac arrest and absence of vital signs, the revival rate was 43 per cent. Those which recovered required four to 10 minutes of acupuncture stimulation”

Paediatric Anaesthesia Study Day


Slide3 l.jpg
Plan Guidelines

  • Evidence evaluation

  • BLS issues

    • AEDs

  • ALS issues

  • Aspects of airway management

  • Conclusions

Paediatric Anaesthesia Study Day


What we know for sure l.jpg
What we know for sure Guidelines

  • Children usually suffer from secondary cardiac arrest

  • In c.90% of cases bradycardia precedes asystole/PEA

  • Survival from respiratory arrest is good (c.70% normal at 1 year)

  • Bystander CPR is associated with improved survival

  • Rescuers often do nothing for fear of causing harm - because they’re scared that “children are different”

Paediatric Anaesthesia Study Day


The big idea l.jpg
The Big Idea Guidelines

A universal guideline for all

Paediatric Anaesthesia Study Day


For every complex problem there is an answer that is simple neat and wrong l.jpg

GuidelinesFor every complex problem there is an answer that is simple, neat and wrong.”

H L Menken

Paediatric Anaesthesia Study Day


Slide7 l.jpg

Effectiveness of ventilation–compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation E. Dorph, L. Wik and P. A. Steen. Resuscitation 2002;54:259

Paediatric Anaesthesia Study Day


Optimum compression ventilation ratio l.jpg
Optimum Compression:Ventilation ratio 2:15 in simulated single rescuer paediatric resuscitation

  • More compressions, better CPP

  • More ventilation better oxygenation

  • Optimum Balance?

Paediatric Anaesthesia Study Day


Optimum compression ventilation ratio babbs cf kern kb resuscitation 2002 54 147 57 l.jpg
Optimum Compression:Ventilation ratio 2:15 in simulated single rescuer paediatric resuscitation Babbs CF, Kern KB. Resuscitation 2002;54:147-57

Paediatric Anaesthesia Study Day


Optimal cpr in children babbs cf nadkarni v resuscitation 2004 61 173 l.jpg
Optimal CPR in Children 2:15 in simulated single rescuer paediatric resuscitation Babbs CF, Nadkarni V. Resuscitation 2004;61:173

“Compression to ventilation ratios in CPR should be smaller for children than for adults and gradually increase as a function of body weight. Optimal CPR in children requires relatively more ventilation than optimal CPR in adults”.

Paediatric Anaesthesia Study Day


Slide11 l.jpg

So much for the 2:15 in simulated single rescuer paediatric resuscitation

“Big Idea”

Paediatric Anaesthesia Study Day


Piglet model of asphyxial cardiac arrest berg et al 1999 crit care med 27 1893 99 l.jpg

CC+V 2:15 in simulated single rescuer paediatric resuscitation

CC

V

No CPR

ROSC

10 /10

6 /10

6 /10

4 /10

ROSC (<2 min)

10 /10

4 /10

6 /10

0 /10

1-h survival

10 /10

6 /10

6 /10

4 /10

24-h survival

8 /10

5 /10

6 /10

0 /10

24-h neurologically normal

8 /10

4 /10

6 /10

0 /10

Piglet Model of Asphyxial Cardiac ArrestBerg et al 1999. Crit Care Med;27:1893-99

Paediatric Anaesthesia Study Day


Doing anything is better than doing nothing l.jpg
Doing anything is better than doing nothing 2:15 in simulated single rescuer paediatric resuscitation

  • Ideally children should have a lower compression/ventilation ratio than adults

  • It’s no use having an ideal if no-one does anything

Paediatric Anaesthesia Study Day


Solution l.jpg
Solution 2:15 in simulated single rescuer paediatric resuscitation

  • Those “with a duty to respond” will do something. They should employ the optimum, evidence based, sequence

  • Other responders should be encouraged to do something by making only minimal necessary modifications to the adult protocol

Paediatric Anaesthesia Study Day


Bls simplifications l.jpg
BLS simplifications 2:15 in simulated single rescuer paediatric resuscitation

  • Much of the wording harmonised with the adult text

  • Age limits: If you think the victim is a child, then he/she is!

  • Chest compression landmarks – avoiding abdominal compression

  • AEDs

Paediatric Anaesthesia Study Day


Slide17 l.jpg
AEDs 2:15 in simulated single rescuer paediatric resuscitation

Problem is not giving too large a shock to a child in VF

Problem is giving ANY shock to child not in VF

Paediatric Anaesthesia Study Day


Fear of doing harm l.jpg
Fear of Doing Harm 2:15 in simulated single rescuer paediatric resuscitation

  • LD50 of shock = 470J/kgBabbs et al. Am Heart J 1980;99:734-738

  • LD100 = 0Jkg (if in VF)

Paediatric Anaesthesia Study Day


Aeds in children rhythm analysis l.jpg
AEDs In Children: 2:15 in simulated single rescuer paediatric resuscitation Rhythm Analysis

Hazinski et al; Circulation 1997Sensitivity 100%; Specificity 100%

Atkins et al; Pediatrics 1998Sensitivity 88%; Specificity 100%

Ceccin et al; Circulation 2002Sensitivity 100% for VF; Specificity 100%

Paediatric Anaesthesia Study Day


Heartstart fr2 automated external defibrillator 50j attenuator l.jpg
Heartstart® FR2 Automated External Defibrillator 2:15 in simulated single rescuer paediatric resuscitation (50J attenuator)

Paediatric Anaesthesia Study Day


Attenuated aeds atkins dl jorgenson db resuscitation 2005 66 31 37 l.jpg
Attenuated AEDs 2:15 in simulated single rescuer paediatric resuscitation Atkins DL, Jorgenson DB. Resuscitation 2005;66:31-37

Pads applied to 27 Patients

  • 8 were in VF (age: 4.5 months - 10 years)

  • Shocks were advised and delivered to all

  • No shock advised to any of the others

  • All 8 defibrillated and admitted to hospital

  • 5 discharged

Paediatric Anaesthesia Study Day


Slide22 l.jpg

50 meters this way, you say? 2:15 in simulated single rescuer paediatric resuscitation

Are we going in the right direction?

Paediatric Anaesthesia Study Day


Slide23 l.jpg
ALS 2:15 in simulated single rescuer paediatric resuscitation

  • ALS protocol

  • VF

  • Dose of adrenaline

  • Airway management

Paediatric Anaesthesia Study Day


Rhythm samson r nadkarni v et al nejm 2006 354 2328 l.jpg
Rhythm 2:15 in simulated single rescuer paediatric resuscitation Samson R, Nadkarni V et al. NEJM 2006;354:2328

Prospective study of 1005 children with

in-hospital cardiac arrest:

  • Non-shockable rhythm 73%

    • Survival 27%

  • Shockable rhythm 27%

    • Survival:

      • 35% (if VF initial rhythm)

      • 11% (if VF occurred subsequently)

Paediatric Anaesthesia Study Day


Slide25 l.jpg

Paediatric Anaesthesia Study Day 2:15 in simulated single rescuer paediatric resuscitation


Vf protocol l.jpg
VF Protocol 2:15 in simulated single rescuer paediatric resuscitation

  • Different aetiology - therefore consider precipitating causes

  • Otherwise, no reason to differ from adult sequence

  • 4J/kg only

Paediatric Anaesthesia Study Day


Dose of adrenaline l.jpg
Dose of Adrenaline? 2:15 in simulated single rescuer paediatric resuscitation

10mcg/kg?

100mcg/kg?

For the 1st dose

For the 2nd dose

For subsequent doses

Paediatric Anaesthesia Study Day


High dose adrenaline l.jpg
High dose adrenaline 2:15 in simulated single rescuer paediatric resuscitation

  • Supported by animal studies and a single retrospective study in children:

  • No other studies have shown benefit

0/20 survivors after at least two SDE (historical control group)

14/20 survivors with HDE after two failed SDE

8/20 survived to discharge

3/20 neurologically intact at follow-up

Goetting. Annals Emerg Med 1991

Paediatric Anaesthesia Study Day


High dose adrenaline29 l.jpg
High dose adrenaline 2:15 in simulated single rescuer paediatric resuscitation

  • Perondi et al NEJM 2004;250:1722-30

    • Blinded PRCT

    • 68 subjects randomised to HDE or SDE after 1x failed SDE

    • 24 hr survival HDE: 1/34 SDE: 7/34

    • Difference significant, but not maintained following adjustment for differences between the 2 groups

    • Significantly reduced survival from asphyxial arrest in HDE group

Paediatric Anaesthesia Study Day


Airway management l.jpg
Airway Management 2:15 in simulated single rescuer paediatric resuscitation

  • The “Gold Standard”

  • LMA

  • Cuffed tracheal tubes

  • Other devices

Paediatric Anaesthesia Study Day


Slide31 l.jpg

Effect of out-of-hospital paediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.JAMA. 2000 Feb 9;283(6):783-90. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS.

  • Prospective randomised controlled trial

  • 830 consecutive patients (<12 years old)

  • Randomised to BVM or ETI on odd or even dates

  • Outcomes: survival to hospital discharge and neurological status on discharge

Paediatric Anaesthesia Study Day


Outcome by treatment received l.jpg
Outcome by Treatment Received on survival and neurological outcome: a controlled clinical trial.

ETI group 420 BVM group: 410

Survival

  • ETI: 25/185 (14%)

  • BVM: 208/635 (33%)

    Good neurological outcome

  • ETI: 15/185 (8%)

  • BVM: 162/635 (26%)

    BUT: results were (correctly) analysed on an ‘intention to treat’ basis

Paediatric Anaesthesia Study Day


Gausche et al jama 283 6 783 90 2000 l.jpg
Gausche et al on survival and neurological outcome: a controlled clinical trial.JAMA. 283(6):783-90, 2000

Outcomes

Paediatric Anaesthesia Study Day


Gausche et al jama 283 6 783 90 200034 l.jpg
Gausche et al on survival and neurological outcome: a controlled clinical trial.JAMA. 283(6):783-90, 2000

Complications

Paediatric Anaesthesia Study Day


Lmas lopez gil m brimacombe j et al 1996 l.jpg
LMAs? on survival and neurological outcome: a controlled clinical trial.Lopez-Gil M, Brimacombe J et al. (1996)

  • 8 anaesthesia residents

  • 75 patients each (600 in all)

  • The problem rate per patient for overall, major, and minor problems was 31.5%, 12.8%, and 18.7%, respectively

  • The problem rate decreased from 62% to 2% for overall problems and 23% to 2% for major problems over the 75 patients

Paediatric Anaesthesia Study Day


Cuffed tracheal tubes khine et al anesthesiology 1997 86 627 31 l.jpg
Cuffed Tracheal Tubes on survival and neurological outcome: a controlled clinical trial.Khine et al Anesthesiology 1997;86:627-31

488 children (0-8yrs) undergoing general anaesthesia

  • Initial size tube selected correctly more frequently with cuffed (age/4+3)

  • Less leak

  • Same complication rate

Paediatric Anaesthesia Study Day


Laryngeal tube l.jpg
Laryngeal Tube on survival and neurological outcome: a controlled clinical trial.

  • 0 Newborn <5kg

  • Infant 5-12Kg

  • Child 12-25kg

  • Small adult <155cm

  • Medium adult 155-180cm

  • 5 Large adult >180cm

Paediatric Anaesthesia Study Day


Laryngeal tube vs lma bortone l et al 2006 paed anaesth 16 251 7 l.jpg
Laryngeal Tube on survival and neurological outcome: a controlled clinical trial.vsLMABortone L et al 2006. Paed Anaesth;16:251-7

Paediatric Anaesthesia Study Day


Etco 2 monitoring l.jpg
ETCO on survival and neurological outcome: a controlled clinical trial.2 Monitoring

Tracheal tube placement detection reliable with perfusing rhythm and during transport

What about during cardiac arrest?

(Bhende et al Am J Emerg Med 1996;14:349-50)

  • Sensitivity 85%

  • Specificity 100%

Paediatric Anaesthesia Study Day


Slide40 l.jpg

Questions? on survival and neurological outcome: a controlled clinical trial.

Paediatric Anaesthesia Study Day


Conclusions l.jpg
Conclusions on survival and neurological outcome: a controlled clinical trial.

Paediatric resuscitation guidelines 2005

  • Are evidence based - but it’s not level 1 evidence!

    They are:

  • Simpler for professional rescuers

  • Much simpler for lay rescuers

Paediatric Anaesthesia Study Day


ad