Javier Urbano

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 …

The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation

A large percentage of patients on extracorporeal membrane oxygenation (ECMO) require continuous renal replacement therapy (CRRT) usually performed through a different venous access or by introducing a filter into the ECMO circuit. Here, we evaluated the efficacy and safety of including a CRRT machine in the circuit by connecting its inlet line after the centrifugal pump and its outlet line before the oxygenator. We tested the function of the combined system initially in a closed circuit, followed by an experimental animal study, and, finally, in a clinical trial with six children. Both machines functioned adequately and there were no significant changes in the pressures of the ECMO circuit after the introduction of the CRRT device, thus achieving the preset negative balances and normalization of the serum urea and creatinine concentrations. The mean life of the filters was about 138 h, and only one filter needed changing due to clotting. Our study shows that the introduction of a CRRT device into the ECMO circuit is a safe and effective technique that improves fluid balance, increases filter life, and does not cause complications. For these reasons, this may be a good method for performing CRRT in patients on ECMO.

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 …

Hypophosphatemia and phosphate supplementation during continuous renal replacement therapy in children

Severe hypophosphatemia can cause generalized muscle weakness, paralysis of the respiratory muscles, myocardial dysfunction, reduced peripheral vascular resistance, and encephalopathy. Here we conducted a prospective study to determine the incidence of hypophosphatemia in 47 children on continuous renal replacement therapy and to evaluate the efficacy and safety of adding phosphate to the replacement and dialysate solutions of 38 pediatric patients. During continuous renal replacement therapy, 68% of patients were found to have hypophosphatemia, significantly more than the 12% of patients at the beginning of therapy. There was no higher incidence of hypophosphatemia among patients requiring insulin, diuretics, parenteral nutrition, or high doses of vasoactive drugs. In the children to whom phosphate was not added to replacement and dialysate solutions, 85% presented with an incidence of hypophosphatemia and 36% required intravenous phosphate replacement, rates significantly higher than in those patients where phosphate was added to the solutions. Phosphate supplementation did not cause any instability of the mixtures or other complications. We show here that the incidence of hypophosphatemia in children on continuous renal replacement therapy is very high. Further, we show that the addition of phosphate to replacement and dialysate solutions is safe and that it reduces the incidence of hypophosphatemia and the need for intravenous phosphate treatment.

Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study

IntroductionContinuous renal replacement therapy (CRRT) frequently gives rise to complications in critically ill children. However, no studies have analyzed these complications prospectively. The purpose of this study was to analyze the complications of CRRT in children and to study the associated risk factors.MethodsA prospective, single-centre, observational study was performed in all critically ill children treated using CRRT in order to determine the incidence of complications related to the technique (problems of catheterization, hypotension at the time of connection to the CRRT, hemorrhage, electrolyte disturbances) and their relationship with patient characteristics, clinical severity, need for vasoactive drugs and mechanical ventilation, and the characteristics of the filtration techniques.ResultsOf 174 children treated with CRRT, 13 (7.4%) presented problems of venous catheterization; this complication was significantly more common in children under 12 months of age and in those weighing less than 10 kg. Hypotension on connection to CRRT was detected in 53 patients (30.4%). Hypotension was not associated with any patient or CRRT characteristics. Clinically significant hemorrhage occurred in 18 patients (10.3%); this complication was not related to any of the variables studied. The sodium, chloride, and phosphate levels fell during the first 72 hours of CRRT; the changes in electrolyte levels during the course of treatment were not found to be related to any of the variables analyzed, nor were they associated with mortality.ConclusionsCRRT-related complications are common in children and some are potentially serious. The most common are hypotension at the time of connection and electrolyte disturbances. Strict control and continuous monitoring of the technique are therefore necessary in children on CRRT.

Circuit life span in critically ill children on continuous renal replacement treatment: a prospective observational evaluation study.

IntroductionOne of the greatest problems with continuous renal replacement therapy (CRRT) is early coagulation of the filters. Few studies have monitored circuit function prospectively. The purpose of this study was to determine the variables associated with circuit life in critically ill children with CRRT.MethodsA prospective observational study was performed in 122 children treated with CRRT in a pediatric intensive care unit from 1996 to 2006. Patient and filter characteristics were analyzed to determine their influence on circuit life. Data were collected on 540 filters in 122 patients and an analysis was performed of the 365 filters (67.6%) that were changed due to circuit coagulation.ResultsThe median circuit life was 31 hours (range 1 to 293 hours). A univariate and multivariate logistic regression study was performed to assess the influence of each one of the factors on circuit life span. No significant differences in filter life were found according to age, weight, diagnoses, pump, site of venous access, blood flow rate, ultrafiltration rate, inotropic drug support, or patient outcome. The mean circuit life span was longer when the heparin dose was greater than 20 U/kg per hour (39 versus 29.1 hours; P = 0.008), with hemodiafiltration compared with hemofiltration (34 versus 22.7 hours; P = 0.001), with filters with surface areas of 0.4 to 0.9 m2 (38.2 versus 26.1 hours; P = 0.01), and with a catheter size of 6.5 French or greater (33.0 versus 25.0 hours; P = 0.04). In the multivariate analysis, hemodiafiltration, heparin dose of greater than 20 U/kg per hour, filter surface area of 0.4 m2 or greater, and initial creatinine of less than 2 mg/dL were associated with a filter life of more than 24 and 48 hours. Total effluent rate of greater than 35 mL/kg per hour was associated only with a filter life of more than 24 hours.ConclusionCircuit life span in CRRT in children is short but may be increased by the use of hemodiafiltration, higher heparin doses, and filters with a high surface area.

Backboards are important when chest compressions are provided on a soft mattress

AIM Determine the impact of backboard placement, torso weight and bed compression on chest compression (CC) depth feedback in simulated cardiac arrest patients. METHODS Epochs of 50 high quality CCs with real-time feedback of sternum-to-spine compression depth were provided by a blinded BLS/ACLS/PALS certified provider on manikins of two torso weights (25 vs. 50 kg), using three bed surfaces (stretcher, Stryker hospital bed with Impression mattress, soft Total Care ICU bed), with/without a backboard (BB). Two BB sizes were tested (small: 60 cm × 50 cm; large: 89 cm × 50 cm) in vertical vs. horizontal orientation. Mattress displacement was measured using an accelerometer placed internally on the spine plate of the manikin. Mattress displacement of ≥ 5 mm was prospectively defined as the minimal clinically important difference. RESULTS During CPR (CC depth: 51.8 ± 2.8mm), BB use significantly reduced mattress displacement only for soft ICU beds. Mattress displacement was reduced (vs. no BB) for 25 kg torso weight: small BB12.3mm (95%CI 11.9-12.6), horizontally oriented large BB 11.2mm (95%CI 10.8-11.7), and vertically oriented large BB 12.2mm (95%CI 11.8-12.6), and for 50 kg torso weight: small BB 7.4mm (95%CI 7.1-7.8), horizontally oriented large BB 7.9 mm (95%CI 7.6-8.3), and vertically oriented large BB 6.2mm (95%CI 5.8-6.5; all p<0.001). BB size and orientation did not significantly affect mattress displacement. Lighter torso weight was associated with larger displacement in soft ICU beds without BB (difference: 6.9 mm, p<0.001). CONCLUSION BB is important for CPR when performed on soft surfaces, such as ICU beds, especially when torso weight is light. BB may not be needed on stretchers, relatively firm hospital beds, or for patients with heavy torso weights.

Enteral Nutrition in the Critically Ill Child: Comparison of Standard and Protein-Enriched Diets

OBJECTIVE To compare a standard diet and a protein-enriched diet in critically ill children. STUDY DESIGN In this prospective randomized controlled trial in critically ill children, all patients received enteral nutrition exclusively and were randomly assigned to a standard diet or a protein-enriched diet (1.1 g protein/100 mL of feeding formula). Blood and urine tests, nitrogen balance assessment, and energy expenditure testing by indirect calorimetry were performed before the beginning of the nutrition regimen and at 24 hours, 72 hours, and 5 days after initiation. Demographic data and pediatric mortality risk scores were recorded. RESULTS Fifty-one children were randomized, and 41 completed the study. Of these, 21 patients received standard formula and 20 received a protein-enriched formula. There were no between-group differences in terms age, sex, diagnosis, or mortality risk scores. There was a greater positive trend in levels of prealbumin, transferrin, retinol-binding protein, and total protein in the protein-enriched diet group. These differences were significant only for retinol-binding protein. The positive nitrogen balance trend was also higher in the protein-enriched diet group; however, this difference did not reach statistical significance. No adverse effects or hyperproteinemia were detected in the protein-enriched diet group. CONCLUSIONS The standard diet provides insufficient protein delivery to critically ill children. Enteral protein supplementation is safe and can improve some biochemical parameters of protein metabolism.

Pulmonary arterial thermodilution, femoral arterial thermodilution and bioreactance cardiac output monitoring in a pediatric hemorrhagic hypovolemic shock model

AIM Bioreactance is a new non-invasive method for cardiac output measurement (NICOM). There are no studies that have analysed the utility of this technique in a pediatric animal model of hemorrhagic shock. METHODS A prospective study was performed using 9 immature Maryland pigs weighing 9 to 12 kg was performed. A Swan-Ganz catheter, a PiCCO catheter and 4 dual surface electrodes were placed at the four corners of the anterior thoracic body surface. Shock was induced by withdrawing a blood volume of 30 mL/kg, and then after, 30 mL/kg of Normal saline was administered. Seven simultaneous measurements of cardiac index (CI) were made by pulmonary artery thermodilution (PATD), Femoral artery thermodilution (FATD), and NICOM before, during, and after hypovolaemia and during and after volume expansion. RESULTS The mean difference (bias) of differences (limits of agreement) between PATD and FATD was 0.84 (-1.87-3.51)L/min/1.77 m(2), between PATD and NICOM was 1.95 (-1.79-5.69)L/min/1.77 m(2), and between FATD and NICOM was 1.06 (-1.40-3.52)L/min/1.77 m(2). A moderate correlation was found between PATD and FATD (r=0.43; P=0.01), but no correlation was found between bioreactance and either PATD or FATD. Hypovolemia and volume expansion produced important significant differences in CI as measured by PATD and FATD, while the changes with bioreactance were small and non significant. CONCLUSIONS PATD and FATD measurements showed similar responses to hypovolemic shock and volume expansion. Bioreactance persistently underestimates the CI and is not significantly altered by either inducing hemorrhagic shock, or later, through volume expansion. Bioreactance is not a suitable method for monitoring the CI in pediatric hemorrhagic shock.

Relationship between energy expenditure, nutritional status and clinical severity before starting enteral nutrition in critically ill children

The objective of the present study was to investigate the relationship between energy expenditure (EE), biochemical and anthropometric nutritional status and severity scales in critically ill children. We performed a prospective observational study in forty-six critically ill children. The following variables were recorded before starting nutrition: age, sex, diagnosis, weight, height, risk of mortality according to the Paediatric Risk Score of Mortality (PRISM), the Revised Paediatric Index of Mortality (PIM2) and the Paediatric Logistic Organ Dysfunction (PELOD) scales, laboratory parameters (albumin, total proteins, prealbumin, transferrin, retinol-binding protein, cholesterol and TAG, and nitrogen balance) and EE measured by indirect calorimetry. The results showed that there was no relationship between EE and clinical severity evaluated using the PRISM, PIM2 and PELOD scales or with the anthropometric nutritional status or biochemical alterations. Finally, it was concluded that neither nutritional status nor clinical severity is related to EE. Therefore, EE must be measured individually in each critically ill child using indirect calorimetry.