Anne-Marie Guerguerian

Part 6: Pediatric basic life support and pediatric advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

Continuous Monitoring of Cerebrovascular Pressure Reactivity After Traumatic Brain Injury in Children

OBJECTIVE: We hypothesized that pressure reactivity index (PRx) values indicating preserved cerebrovascular pressure autoregulation would be associated with survival in children with traumatic brain injury (TBI). This hypothesis was tested in a prospective, blinded, observational, pilot study. METHODS: Twenty-one children admitted between May 2006 and September 2008 with severe TBI necessitating invasive intracranial pressure monitoring were enrolled in this study. The PRx was continuously monitored as a moving, linear correlation coefficient between low-frequency waves of intracranial and arterial blood pressures. Positive values of PRx approaching 1 indicate impaired cerebrovascular pressure reactivity, whereas negative PRx values or values close to 0 indicate preserved cerebrovascular pressure reactivity. Survival was the primary outcome and was compared with the average PRx value obtained during the intracranial pressure-monitoring period. RESULTS: PRx was associated with survival in this cohort; survivors (N = 15) had a mean PRx ± SD of 0.08 ± 0.19, and nonsurvivors (N = 6) had a mean PRx of 0.69 ± 0.21 (P = .0009). In this sample, continuous PRx monitoring suggested impaired cerebrovascular pressure reactivity at low levels of cerebral perfusion pressure (CPP) and intact cerebrovascular pressure reactivity at higher levels of CPP. CONCLUSIONS: Intact cerebrovascular pressure reactivity quantified with the PRx is associated with survival after severe head trauma in children. The PRx is CPP dependent in children. The PRx may be useful for defining age-specific and possibly patient-specific optimal targets for CPP after TBI.

A Review of EEG-Based Brain-Computer Interfaces as Access Pathways for Individuals with Severe Disabilities

Electroencephalography (EEG) is a non-invasive method for measuring brain activity and is a strong candidate for brain-computer interface (BCI) development. While BCIs can be used as a means of communication for individuals with severe disabilities, the majority of existing studies have reported BCI evaluations by able-bodied individuals. Considering the many differences in body functions and usage scenarios between individuals with disabilities and able-bodied individuals, involvement of the target population in BCI evaluation is necessary. In this review, 39 studies reporting EEG-oriented BCI assessment by individuals with disabilities were identified in the past decade. With respect to participant populations, a need for assessing BCI performance for the pediatric population with severe disabilities was identified as an important future direction. Acquiring a reliable communication pathway during early stages of development is crucial in avoiding learned helplessness in pediatric-onset disabilities. With respect to evaluation, augmenting traditional measures of system performance with those relating to contextual factors was recommended for realizing user-centered designs appropriate for integration in real-life. Considering indicators of user state and developing more effective training paradigms are recommended for future studies of BCI involving individuals with disabilities.

Massive diltiazem overdose treated with extracorporeal membrane oxygenation.

Objective To describe a case of massive diltiazem overdose with a good outcome achieved after early and aggressive supportive therapy. Design Case report. Setting Pediatric Critical Care Unit. Patient Sixteen-year-old adolescent girl. Measurements and Main Results A 16-yr-old adolescent girl presented to the emergency department 6 hrs after the intentional ingestion of 40 300-mg sustained-release diltiazem tablets (12 g of Cardura CD). She was hypotensive and required a glucagon and epinephrine infusion despite initial fluid resuscitation with saline and intravenous calcium (1 g). Multiple asystolic cardiac arrests ensued which became increasingly refractory to high-dose epinephrine. Hemodynamic support was achieved with a 48-hr period of extracorporeal membrane oxygenation for atrial standstill. Severe multiorgan dysfunction ensued (cardiac, neurologic, renal, hepatic, gastrointestinal, hematologic, and metabolic). Plasma diltiazem and its metabolites were measured and its half-life was reported between 28 and 48 hrs. A sustained decline in plasma diltiazem levels and its metabolites was not observed after two periods of charcoal hemoperfusion. Recovery of organ function occurred with sinus rhythm noted on the ninth day. The patient made a full recovery and was discharged from the critical care unit after 15 days. Conclusions Although massive calcium channel blocker overdose can produce profound and prolonged cardiac or multiorgan dysfunction, its toxic effects may be reversible. Supportive therapy, particularly of the cardiovascular system, is the most important goal.

Critical illness in children with influenza A/pH1N1 2009 infection in Canada*

Objective: To describe characteristics, treatment, and outcomes of critically ill children with influenza A/pandemic influenza A virus (pH1N1) infection in Canada. Design: An observational study of critically ill children with influenza A/pH1N1 infection in pediatric intensive care units (PICUs). Setting: Nine Canadian PICUs. Patients: A total of 57 patients admitted to PICUs between April 16, 2009 and August 15, 2009. Interventions: None. Measurements and Main Results: Characteristics of critically ill children with influenza A/pH1N1 infection were recorded. Confirmed intensive care unit cases were compared with a national surveillance database containing all hospitalized pediatric patients with influenza A/pH1N1 infection. Risk factors were assessed with a Cox proportional hazard model. The PICU cohort and national surveillance data were compared, using chi-square tests. Fifty-seven children were admitted to the PICU for community-acquired influenza A/pH1N1 infection. One or more chronic comorbid illnesses were observed in 70.2% of patients, and 24.6% of patients were aboriginal. Mechanical ventilation was used in 68% of children, 20 children (35.1%) had acute lung injury on the first day of admission, and the median duration of ventilation was 6 days (range, 0–67 days). The PICU mortality rate was 7% (4 of 57 patients). When compared with nonintensive care unit hospitalized children, PICU children were more likely to have a chronic medical condition (relative risk, 1.73); aboriginal ethnicity was not a risk factor of intensive care unit admission. Conclusions: During the first outbreak of influenza A/pH1N1 infection, when the population was naïve to this novel virus, severe illness was common among children with underlying chronic conditions and aboriginal children. Influenza A/pH1N1-related critical illness in children was associated with severe hypoxemic respiratory failure and prolonged mechanical ventilation. However, this higher rate and severity of respiratory illness did not result in an increased mortality when compared with seasonal influenza.

Automatic detection of a prefrontal cortical response to emotionally rated music using multi-channel near-infrared spectroscopy

Emotional responses can be induced by external sensory stimuli. For severely disabled nonverbal individuals who have no means of communication, the decoding of emotion may offer insight into an individuals state of mind and his/her response to events taking place in the surrounding environment. Near-infrared spectroscopy (NIRS) provides an opportunity for bed-side monitoring of emotions via measurement of hemodynamic activity in the prefrontal cortex, a brain region known to be involved in emotion processing. In this paper, prefrontal cortex activity of ten able-bodied participants was monitored using NIRS as they listened to 78 music excerpts with different emotional content and a control acoustic stimuli consisting of the Brown noise. The participants rated their emotional state after listening to each excerpt along the dimensions of valence (positive versus negative) and arousal (intense versus neutral). These ratings were used to label the NIRS trial data. Using a linear discriminant analysis-based classifier and a two-dimensional time-domain feature set, trials with positive and negative emotions were discriminated with an average accuracy of 71.94% ± 8.19%. Trials with audible Brown noise representing a neutral response were differentiated from high arousal trials with an average accuracy of 71.93% ± 9.09% using a two-dimensional feature set. In nine out of the ten participants, response to the neutral Brown noise was differentiated from high arousal trials with accuracies exceeding chance level, and positive versus negative emotional differentiation accuracies exceeded the chance level in seven out of the ten participants. These results illustrate that NIRS recordings of the prefrontal cortex during presentation of music with emotional content can be automatically decoded in terms of both valence and arousal encouraging future investigation of NIRS-based emotion detection in individuals with severe disabilities.

Developmental Changes in Prostaglandin E 2 Receptor Subtypes in Porcine Ductus Arteriosus Possible Contribution in Altered Responsiveness to Prostaglandin E 2

BACKGROUND Prostaglandin E(2) (PGE(2)) is important in ductus arteriosus (DA) patency, but the types of functional PGE(2) receptors (EP) in the developing DA are not known. We postulated that age-dependent alterations in EP and/or their subtypes may possibly contribute to the reduced responsiveness of the newborn DA to PGE(2). METHODS AND RESULTS We determined PGE(2) receptor subtypes by competition binding and immunoblot studies on the DA of fetal ( approximately 75% and 90% gestation) and newborn (<45 minutes old) pigs. We studied the effects of EP receptor stimulation on cAMP signaling in vitro and on term newborn (<3 hours old) DA patency in vivo. Fetal pig DA expressed EP(2), EP(3), and EP(4) receptors equivalently, but not EP(1). In neonatal DA, EP(1), EP(3), and EP(4) were undetectable, whereas EP(2) density was similar in fetus and newborn. Prostaglandin-induced changes in cAMP mirrored binding data. 16,16-Dimethyl PGE(2) and 11-deoxy PGE(1) (EP(2)/EP(3)/EP(4) agonist) produced more cAMP in fetus than newborn, but butaprost (selective EP(2) agonist) caused similar cAMP increases in both; EP(3) and EP(4) ligands (M&B28767 and AH23848B, respectively) affected cAMP production only in fetus. After birth, administration of butaprost alone was as effective as 11-deoxy PGE(1) and 16,16-dimethyl PGE(2) in dilating DA in vivo. CONCLUSIONS The data reveal fewer PGE(2) receptors in the DA of the newborn than in that of the fetus; this may contribute to the decreased responsiveness of the DA to PGE(2) in newborn. Because EP(2) receptors seem to mediate the effects of PGE(2) on the newborn DA, one may propose that a selective EP(2) agonist may be preferred as a pharmacological agent to maintain DA patency in infants with certain congenital heart diseases.

Part 6: Pediatric basic life support and pediatric advanced life support

The Pediatric Task Force reviewed all questions submitted by the International Liaison Committee on Resuscitation (ILCOR) member councils in 2010, reviewed all council training materials and resuscitation guidelines and algorithms, and conferred on recent areas of interest and controversy. We identified a few areas where there were key differences in council-specific guidelines based on historical recommendations, such as the A-B-C (Airway, Breathing, Circulation) versus C-A-B (Circulation, Airway, Breathing) sequence of provision of cardiopulmonary resuscitation (CPR), initial back blows versus abdominal thrusts for foreign-body airway obstruction, an upper limit for recommended chest compression rate, and initial defibrillation dose for shockable rhythms (2 versus 4 J/kg). We produced a working list of prioritized questions and topics, which was adjusted with the advent of new research evidence. This led to a prioritized palate of 21 PICO (population, intervention, comparator, outcome) questions for ILCOR task force focus. The 2015 process was supported by information specialists who performed in-depth systematic searches, liaising with pediatric content experts so that the most appropriate terms and outcomes and the most relevant publications were identified. Relevant adult literature was considered (extrapolated) in those PICO questions that overlapped with other task forces, or when there were insufficient pediatric data. In rare circumstances (in the absence of sufficient human data), appropriate animal studies were incorporated into reviews of the literature. However, these data were considered only when higher levels of evidence were not available and the topic was deemed critical. When formulating the PICO questions, the task force felt it important to evaluate patient outcomes that extend beyond return of spontaneous circulation (ROSC) or discharge from the pediatric intensive care unit (PICU). In recognition that the measures must have meaning, not only to clinicians but also to parents and caregivers, longer-term outcomes at 30 …

A Brain-Computer Interface Based on Bilateral Transcranial Doppler Ultrasound

In this study, we investigate the feasibility of a BCI based on transcranial Doppler ultrasound (TCD), a medical imaging technique used to monitor cerebral blood flow velocity. We classified the cerebral blood flow velocity changes associated with two mental tasks - a word generation task, and a mental rotation task. Cerebral blood flow velocity was measured simultaneously within the left and right middle cerebral arteries while nine able-bodied adults alternated between mental activity (i.e. word generation or mental rotation) and relaxation. Using linear discriminant analysis and a set of time-domain features, word generation and mental rotation were classified with respective average accuracies of 82.9%10.5 and 85.7%10.0 across all participants. Accuracies for all participants significantly exceeded chance. These results indicate that TCD is a promising measurement modality for BCI research.

The influence of systemic hemodynamics and oxygen transport on cerebral oxygen saturation in neonates after the Norwood procedure.

OBJECTIVES Ischemic brain injury is an important morbidity in neonates after the Norwood procedure. Its relationship to systemic hemodynamic oxygen transport is poorly understood. METHODS Sixteen neonates undergoing the Norwood procedure were studied. Continuous cerebral oxygen saturation was measured by near-infrared spectroscopy. Continuous oxygen consumption was measured by respiratory mass spectrometry. Pulmonary and systemic blood flow, systemic vascular resistance, oxygen delivery, and oxygen extraction ratio were derived with measurements of arterial, and superior vena cava and pulmonary venous gases and pressures at 2- to 4-hour intervals during the first 72 hours in the intensive care unit. RESULTS Mean cerebral oxygen saturation was 66% +/- 12% before the operation, reduced to 51% +/- 13% on arrival in the intensive care unit, and remained low during the first 8 hours; it increased to 56% +/- 9% at 72 hours, still significantly lower than the preoperative level (P < .05). Postoperatively, cerebral oxygen saturation was closely and positively correlated with systemic arterial pressure, arterial oxygen saturation, and arterial oxygen tension and negatively with oxygen extraction ratio (P < .0001 for all). Cerebral oxygen saturation was moderately and positively correlated with systemic blood flow and oxygen delivery (P < .0001 for both). It was weakly and positively correlated with pulmonary blood flow (P = .001) and hemoglobin (P = .02) and negatively correlated with systemic vascular resistance (P = .003). It was not correlated with oxygen consumption (P > .05). CONCLUSIONS Cerebral oxygen saturation decreased significantly in neonates during the early postoperative period after the Norwood procedure and was significantly influenced by systemic hemodynamic and metabolic events. As such, hemodynamic interventions to modify systemic oxygen transport may provide further opportunities to reduce the risk of cerebral ischemia and improve neurodevelopmental outcomes.