To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest.
Retrospective, secondary analysis of 200 swine ...resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30 s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC).
During BLS, DBP peaked between 1–3 min and was greater in survivors (20.0 11.3, 33.3 mmHg) than in non-survivors (5.0 1.0, 10.0 mmHg; p < 0.001). After this transient increase, the DBP in survivors progressively decreased but remained greater than that of non-survivors after 10 min of resuscitation (9.0 6.0, 13.8 versus 3.0 1.0, 6.8 mmHg; p < 0.001). During ALS, the magnitude of DBP change after the first adrenaline (epinephrine) administration was greater in survivors (22.0 16.5, 36.5 mmHg) than in non-survivors (6.0 2.0, 11.0 mmHg; p < 0.001). Survival rate was greater when DBP improved by ≥26 mmHg after the first dose of adrenaline (20/21; 95%) than when DBP improved by ≤10 mmHg (1/99; 1%). The magnitude of DBP change after the first adrenaline administration correlated with the timetoROSC (r = −0.54; p < 0.001).
Survival after asphyxial cardiac arrest is associated with a higher DBP throughout resuscitation, but the difference between survivors and non-survivors was reduced after prolonged BLS. During ALS, response to adrenaline administration correlates with survival and time to ROSC. If confirmed clinically, these findings may be useful for titrating adrenaline during resuscitation and prognosticating likelihood of ROSC.
Institutional Protocol Numbers: SW14M223 and SW17M101
To determine whether end-tidal CO2-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation after prolonged asphyxial arrest.
Preclinical randomized controlled ...study.
University animal research laboratory.
1-2-week-old swine.
After undergoing a 20-minute asphyxial arrest, animals received either standard or end-tidal CO2-guided cardiopulmonary resuscitation. In the standard group, chest compression delivery was optimized by video and verbal feedback to maintain the rate, depth, and release within published guidelines. In the end-tidal CO2-guided group, chest compression rate and depth were adjusted to obtain a maximal end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation.
Mean end-tidal CO2 at 10 minutes of cardiopulmonary resuscitation was 34 ± 8 torr in the end-tidal CO2 group (n = 14) and 19 ± 9 torr in the standard group (n = 14; p = 0.0001). The return of spontaneous circulation rate was 7 of 14 (50%) in the end-tidal CO2 group and 2 of 14 (14%) in the standard group (p = 0.04). The chest compression rate averaged 143 ± 10/min in the end-tidal CO2 group and 102 ± 2/min in the standard group (p < 0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of end-tidal CO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the end-tidal CO2 group than in the standard group (p = 0.01 and p = 0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups.
End-tidal CO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing end-tidal CO2 levels during cardiopulmonary resuscitation required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during cardiopulmonary resuscitation has the potential to provide optimized and individualized resuscitative efforts.
Background
End‐tidal carbon dioxide (ETCO2) correlates with systemic blood flow and resuscitation rate during cardiopulmonary resuscitation (CPR) and may potentially direct chest compression ...performance. We compared ETCO2‐directed chest compressions with chest compressions optimized to pediatric basic life support guidelines in an infant swine model to determine the effect on rate of return of spontaneous circulation (ROSC).
Methods and Results
Forty 2‐kg piglets underwent general anesthesia, tracheostomy, placement of vascular catheters, ventricular fibrillation, and 90 seconds of no‐flow before receiving 10 or 12 minutes of pediatric basic life support. In the optimized group, chest compressions were optimized by marker, video, and verbal feedback to obtain American Heart Association‐recommended depth and rate. In the ETCO2‐directed group, compression depth, rate, and hand position were modified to obtain a maximal ETCO2 without video or verbal feedback. After the interval of pediatric basic life support, external defibrillation and intravenous epinephrine were administered for another 10 minutes of CPR or until ROSC. Mean ETCO2 at 10 minutes of CPR was 22.7±7.8 mm Hg in the optimized group (n=20) and 28.5±7.0 mm Hg in the ETCO2‐directed group (n=20; P=0.02). Despite higher ETCO2 and mean arterial pressure in the latter group, ROSC rates were similar: 13 of 20 (65%; optimized) and 14 of 20 (70%; ETCO2 directed). The best predictor of ROSC was systemic perfusion pressure. Defibrillation attempts, epinephrine doses required, and CPR‐related injuries were similar between groups.
Conclusions
The use of ETCO2‐directed chest compressions is a novel guided approach to resuscitation that can be as effective as standard CPR optimized with marker, video, and verbal feedback.
Abstract Background Thermal epiglottitis is a rare but potentially life-threatening disease. Diagnosis requires a thorough history and high clinical level of suspicion, particularly in children. ...Thermal epiglottitis from steam inhalation can have a slow onset without oropharyngeal signs of thermal injury, findings that can hide the clinical diagnosis. Objective Our aim was to review the pathophysiology and clinical presentation of thermal epiglottitis and the challenges involved in diagnosis and management of this form of atypical epiglottitis. Case Report We describe the case of a 22-month-old male presenting to the pediatric emergency department after a scald burn from steam and boiling water resulting in 12% body surface area burns to his chin, chest, and shoulder, with no obvious oropharyngeal or neck injuries. At the time of presentation, he was afebrile and well appearing. Six hours after the injury, he was sitting in the “tripod position,” drooling, with pooled saliva in his mouth and inspiratory stridor. Intubation in the operating room using conventional direct laryngoscopy was not successful and he was intubated using an operative endoscope. Laryngoscopy demonstrated thermal epiglottitis. A tracheostomy was performed to secure the airway, and he was admitted to the pediatric intensive care unit. He was discharged home and decannulated 4 weeks later, when airway endoscopy showed complete recovery with normal airway structures. Conclusion A thorough history and physical examination together with a high level of suspicion and aggressive, collaborative airway management is vital in preventing catastrophic airway obstruction in atypical forms of epiglottitis.
Williams syndrome (WS) is a congenital, multisystem disorder affecting the cardiovascular, connective tissue, and central nervous systems in 1 in 10 000 live births. Cardiovascular involvement is the ...most common cause of morbidity and mortality in patients with WS, and noninvasive and invasive procedures are common. Sudden cardiovascular collapse in patients with WS is a well-known phenomenon, especially in the peri-procedural period. Detailed guidelines for peri-procedural management of patients with WS are limited. The goal of this review is to provide thoughtful, safe and effective management strategies for the peri-procedural care of patients with WS with careful consideration of hemodynamic impacts of anesthetic strategies. In addition, an expanded risk stratification system for anesthetic administration is provided.
Abstract Introduction Recent adult reports have demonstrated sub-optimal performance of basic cardiopulmonary resuscitation (CPR) skills in advanced training scenarios and real life arrest ...situations. We studied the adequacy of chest compressions performed by advanced trained pediatric providers in code scenarios. Methods We designed a prospective observational study of pediatric providers performing external closed-chest compressions on a child mannequin that is designed to assess adequacy based on depth and rate of chest compressions. The study was conducted from 2008 to 2009 in which 42 subjects were screened and enrolled for participation. Each subject underwent a basic life support scenario that included two minutes of uninterrupted external closed-chest compressions that were assessed for adequacy based on depth and rate. Results For 42 subjects, 168 total 30-s time segments were available for analysis. Chest compressions were performed at a median rate of 110 (interquartile range (IQR) of 75–145) compressions per minute (cpm). No significant decay in rate of chest compressions was noted over the two-minute evaluation. Chest compression depth was adequate in 9.4% of total delivered chest compressions. No statistical significance was found on the job exposure to CPR and delivery of effective chest compressions. Conclusion Advanced training of pediatric providers does not ensure adequate delivery of chest compressions. Rate standards and adequate depth of chest compressions are infrequently achieved and both may need more emphasis in CPR training and attention during resuscitations.
Maximizing operating room (OR) efficiency is essential for hospital cost containment and effective patient throughput. Little data is available regarding the safety and efficacy of extubation of ...children in the post-anesthesia care unit (PACU) by a nurse rather than in the OR. We sought to evaluate the impact of a long-standing practice of PACU extubation upon airway complications and OR efficiency.
The records of 1930 children who underwent inguinal hernia repair, laparoscopic appendectomy or pyloromyotomy at a children's hospital between July, 2018 and June, 2020 were reviewed. Extubations were performed in the OR only when the PACU was inadequately staffed or during the early months of the Covid-19 pandemic. Cases in which there was a deep extubation, a PACU hold was in effect or a patient went directly to an inpatient unit from the OR were excluded. Intra- and post-operative time metrics were recorded and emergency airway interventions were assessed.
1747 operations were evaluated. Time from the end of the procedure to leaving the OR ranged from 4.1 to 4.8 min when extubation was done in the PACU and was 6–9 min less than with OR extubation. (see table). There were 23 airway events (1.5% of all cases) after PACU extubation that necessitated only brief bag-mask ventilation. There were no cases of re-intubation.
In a large population of children undergoing diverse surgical procedures, post-anesthesia care unit extubation was safe and resulted in rapid transfer of patients from the operating room after completion of their operation. Time saved because of shorter operating room times reduces hospital costs and can allow for increased throughput. Extubation in the post-anesthesia care unit may not only be as safe as operating room extubation, but may result in fewer serious airway events as patients may be less likely to have their endotracheal tube removed prematurely.
Treatment Study, Level III
Despite the national HIV and sexually transmissible infection (STI) rates growing in rural areas, rural populations-particularly men who have sex with men (MSM), have limited access to secondary ...(i.e., HIV/STI screening) prevention activities compared with their urban counterparts. We conducted semistructured in-depth interviews with 23 rural MSM residing in Oklahoma and Arkansas to assess their (1) experiences with HIV and STI testing; (2) perceptions of at-home testing; and (3) preferences for receiving results and care. Barriers to accessing HIV/STI screening included lack of medical providers within rural communities, privacy and confidentiality concerns, and perceived stigma from providers and community members. To overcome these barriers, all participants recognized the importance of screening paradigms that facilitated at-home screening, medical consultation, and care. This included the ability to request a testing kit and receive results online, to access affirming and competent providers utilizing telemedicine technology, as well as prompt linkage to treatment. These narratives highlight the need for systems of care that facilitate HIV and STI screening within rural communities, which do not require participants to access services at traditional physical venues.
With decreasing mortality in PICUs, a growing number of survivors experience long-lasting physical impairments. Early physical rehabilitation and mobilization during critical illness are safe and ...feasible, but little is known about the prevalence in PICUs. We aimed to evaluate the prevalence of rehabilitation for critically ill children and associated barriers.
National 2-day point prevalence study.
Eighty-two PICUs in 65 hospitals across the United States.
All patients admitted to a participating PICU for greater than or equal to 72 hours on each point prevalence day.
None.
The primary outcome was prevalence of physical therapy- or occupational therapy-provided mobility on the study days. PICUs also prospectively collected timing of initial rehabilitation team consultation, clinical and patient mobility data, potential mobility-associated safety events, and barriers to mobility. The point prevalence of physical therapy- or occupational therapy-provided mobility during 1,769 patient-days was 35% and associated with older age (adjusted odds ratio for 13-17 vs < 3 yr, 2.1; 95% CI, 1.5-3.1) and male gender (adjusted odds ratio for females, 0.76; 95% CI, 0.61-0.95). Patients with higher baseline function (Pediatric Cerebral Performance Category, ≤ 2 vs > 2) less often had rehabilitation consultation within the first 72 hours (27% vs 38%; p < 0.001). Patients were completely immobile on 19% of patient-days. A potential safety event occurred in only 4% of 4,700 mobility sessions, most commonly a transient change in vital signs. Out-of-bed mobility was negatively associated with the presence of an endotracheal tube (adjusted odds ratio, 0.13; 95% CI, 0.1-0.2) and urinary catheter (adjusted odds ratio, 0.28; 95% CI, 0.1-0.6). Positive associations included family presence in children less than 3 years old (adjusted odds ratio, 4.55; 95% CI, 3.1-6.6).
Younger children, females, and patients with higher baseline function less commonly receive rehabilitation in U.S. PICUs, and early rehabilitation consultation is infrequent. These findings highlight the need for systematic design of rehabilitation interventions for all critically ill children at risk of functional impairments.
PDF
