Katherine Taylor

How best to teach CPR to schoolchildren: A systematic review ☆

BACKGROUND Training schoolchildren to perform cardiopulmonary resuscitation is one possible method of increasing bystander CPR rates. We reviewed available literature to identify what methods of training children have been successful. OBJECTIVES AND METHODS This review sought to evaluate evidence addressing the following PICO question: (P) In schoolchildren, (I) what types of CPR, AED and first aid training (C) when compared to no training and to each other (O) lead to ability to perform life saving measures? Searches were conducted in Ovid MEDLINE (1946 - August 2012), Ovid EMBASE (1974 - August 2012) and Ebscohost Cinahl (1981 - August 2012). Database specific subject headings in all three databases (MeSH in MEDLINE, Emtree in EMBASE, Cinahl Headings) were selected for the concepts of cardiopulmonary resuscitation (CPR) and education. The combined results were then limited by age to include all school aged children. The search yielded 2620 articles. From titles, abstract and key words, 208 articles described CPR, AED and/or first aid training in schoolchildren and were eligible for review. These were obtained in full, were unavailable or not published in English. We reviewed articles for publication type and relevance. 48 studies were identified. One additional study was included as an extension of a study retrieved within the search. RESULTS The studies found by the search were heterogeneous for study and training methodology. Findings regarding schoolchild age and physical factors, the role of practical training, use of self-instruction kits, use of computer based learning, reduced training time, trainer type, AED training are presented. CONCLUSIONS Evidence shows that cardiopulmonary training, delivered in various ways, is successful in a wide age range of children. While older children perform more successfully on testing, younger children are able to perform basic tasks well, including use of AEDs. Chest compression depth correlates with physical factors such as increasing weight, BMI and height. Instruction must include hands on practice to enable children to perform physical tasks. Repeated training improves performance and retention but the format and frequency of repeated training is yet to be fully determined. Types of training that may reduce the main obstacles to implementation of such training in schools include use of self-instruction kits, computer based learning and use of teacher and peer tutor trainers, but again, need further exploration. As starting points we recommend legislative and funded mandates to provide such training to schoolchildren, and production and use of a framework which will delineate longitudinal delivery of training over the school career. Further research should have some uniformity in terms of assessment methodology, look at longer outcomes, and ideally will evaluate areas that are currently poorly defined.

Emergency interventional lung assist for pulmonary hypertension.

We present a 15-yr-old-girl who underwent interventional lung assist via Novalung (Novalung GmbH, Lotzenaecker, Heckingen, Germany) insertion as a bridge to bilateral lung transplantation for pulmonary veno-occlusive disease. This is the first pediatric and smallest patient to receive the device. Central cannulation was chosen to optimize blood flow through the device by enabling larger-sized cannulae in a patient with high pulmonary artery pressure. Novalung provided circulatory support with oxygenation obviating the need for extracorporeal membrane oxygenation while waiting for lung transplantation.

A Comparison of Cardiac Output by Thoracic Impedance and Direct Fick in Children With Congenital Heart Disease Undergoing Diagnostic Cardiac Catheterization

OBJECTIVE(S) To evaluate the measurement of cardiac output (CO) using continuous electrical bioimpedance cardiography (Physioflow; Neumedx, Philadelphia, PA) (CO(PF)) with a simultaneous direct Fick measurement (CO(FICK)) in children with congenital heart disease. DESIGN A prospective cohort study comparing 2 methods of measurement of CO. SETTING A quaternary university-affiliated pediatric hospital. PARTICIPANTS Children undergoing cardiac catheterization for clinical care. INTERVENTIONS The Physioflow measured continuous real time CO in 15-second epochs and simultaneous measurement of cardiac output by direct Fick (with mass spectrometry to assess VO(2)) were acquired. MEASUREMENTS AND MAIN RESULTS Sixty-five patients were recruited, and data from 56 (25 males) were adequate for analysis. The median age at study was 3.5 years (range, 0.4-16.6 years), and the median body surface area was 0.62 m(2) (range, 0.31-1.71). There were 25 of 56 (45%) with univentricular physiology. A total of 19,228 Physioflow data points were available for the analysis of which 14,569 (76%) were valid; 96% of the invalid measurements were identified as artifacts by the device. The average cardiac index of valid measurements was 3.09 ± 0.72 L/min/m(2). Compared with the Fick CO, the mean bias was -0.09 L/min, but the 95% limits of agreement were -3.20 to +3.01 L/min/m(2). Consequently, only 20 of 56 (36%) of measurements were within 20%, and 31 of 56 (55%) of measurements were within 30% of each other. CONCLUSIONS Compared with measurements made by direct Fick, CO measured using the Physioflow device was unreliable in anesthetized children with congenital heart disease.

Poor Accuracy of Noninvasive Cardiac Output Monitoring Using Bioimpedance Cardiography [PhysioFlow®] Compared to Magnetic Resonance Imaging in Pediatric Patients

BACKGROUND: Identification of low cardiac output (CO) states in anesthesia is important because preoperative hemodynamic optimization may improve outcome in surgery. Accurate real-time CO measurement would be useful in optimizing “goal-directed” therapy. We sought to evaluate the reliability and accuracy of CO measurement using bioimpedance cardiography (PhysioFlow®, NeuMeDx, Bristol, PA) in pediatric patients with and without cardiac disease undergoing anesthesia for magnetic resonance imaging (MRI). METHODS: All consenting patients undergoing anesthesia for cardiac MRI were enrolled. After equilibration of anesthesia for ≥10 minutes, 6 PhysioFlow electrodes were applied to the patients chest for continuous real-time monitoring for 10 minutes. Data were stored in 15-second epochs and later averaged offline to obtain CO. Phase contrast MRI measurements of flow volumes in the superior vena cava and ascending and descending aorta were made from a single imaging plane through all 3 vessels at the level of the right pulmonary artery. Both CO measurements were indexed to body surface area. The anesthetic technique was the same for both measurements. Agreement was assessed using Bland-Altman analysis. RESULTS: Thirty-one patients were enrolled and 23 were analyzed. The median age at study was 2.8 years (range, 0.02–8.02 years) and median body surface area was 0.54 m2 (range, 0.21–1.00 m2). Eleven of the 23 patients (48%) were males. Patients were grouped into those with univentricular physiology, 6 of 23 (26%); biventricular physiology with shunt, 3 of 23 (13%); biventricular without shunt, 10 of 23 (43%); and no structural heart disease, 4 of 23 (17%). The mean bias was −0.34 ± 1.50 L/min/m2 (P = 0.29). The 95% limits of agreement were −3.21 to +2.69 L/min/m2. Only 8 of 23 measurements (35%) were within 20% and 14 of 23 measurements (61%) were within 30% of each other. CONCLUSION: PhysioFlow performance was not sufficiently accurate in this population. Modifications of the algorithm and further testing are required before this device can be recommended for routine clinical use in pediatric patients.

The impact of targeted therapies for pulmonary hypertension on pediatric intraoperative morbidity or mortality.

BACKGROUND:Pulmonary hypertension (PHT) is a significant risk factor for major adverse events during anesthesia, with a reported incidence of 5% to 7%, secondary to acute pulmonary hypertensive crises or right ventricular ischemia. Newer therapies for treating PHT have reduced mortality. In this single-center study, we investigated the frequency of major and minor events during anesthesia under the current strategies to manage PHT. METHODS:We reviewed the records of children with PHT who underwent noncardiopulmonary bypass procedures from 2008 to 2012. Clinically important symptoms, physical signs, and results of investigations present before anesthesia were recorded. The incidence and type of intraoperative complications and death (up to 7 days) were collected. RESULTS:Data were collected for 122 patients undergoing 284 procedures. Minor (3.9%) and major (3.2%) complication rates were unchanged from previous publications. The etiology of PHT was not significant for complications (P = 0.14). Disease-modifying agents were not associated with reduced complications: 4.1% in treated versus 8.6% untreated (all P > 0.14). Patients receiving home oxygen had more complications (P = 0.02). Multiple logistic regression identified age and degree of PHT as significant predictors of complications (all P ⩽ 0.03). CONCLUSIONS:The risk for adverse events during anesthesia in patients with PHT remains high, despite newer disease-modifying treatments. Risk factors for complications include age and severity of PHT.

Determinants and clinical significance of flow via the fenestration in the Fontan pathway: A multimodality study

BACKGROUND The use of a fenestration in the Fontan pathway remains controversial, partly because its hemodynamic effects and clinical consequences are insufficiently understood. The objective of this study was to quantify the magnitude of fenestration flow and to characterize its hemodynamic consequences after an intermediate interval after surgery. METHODS Twenty three patients with a fenestrated extracardiac conduit prospectively underwent investigation by cardiac magnetic resonance (CMR), echocardiography, and invasive manometry under the same general anesthetic 12 ± 4 months after Fontan surgery. Fenestration flow was determined using phase contrast CMR by subtracting flow in the Fontan pathway above the fenestration from Fontan flow below the fenestration. RESULTS Fenestration flow constituted a mean of 31 ± 12% (range 8-50%) of ventricular preload. It was associated with a lower Qp/Qs (r = -0.64, p=0.001) and oxygen saturation (r = -0.74, p<0.0001). Fenestration flow volume was correlated with pulmonary vascular resistance (r = 0.45, p = 0.04) and markers of ventricular diastolic function (early diastolic strain rate r = 0.57, p = 0.008 and ventricular untwist rate r = 0.54, p = 0.02). In 14 patients (61%) all of the net inferior vena cava flow and part of the superior vena cava flow were diverted into the systemic atrium and did not reach the lungs. CONCLUSIONS Fenestration flow can be measured accurately with CMR. In two-thirds of the patients not only all of the inferior vena cava flow, but also some of the superior vena cava flow is diverted through the fenestration. Fenestration flow is driven by a balance between pulmonary vascular resistance and early diastolic ventricular function.

Intraoperative management and early postoperative outcomes of pediatric renal transplants

Smaller children are presenting for renal transplantation as the treatment of choice for end‐stage renal disease. Adult donor organs are more successful than pediatric deceased donor organs. An adult kidney may sequester ~75% of the circulating volume of a 5 year‐old child and requires significantly increased cardiac output to maintain renal perfusion. Treatment includes volume, inotropic or vasopressor agents, or central neuroaxial blockade for sympatholysis.

Cardiac arrest upon induction of anesthesia in children with cardiomyopathy: an analysis of incidence and risk factors

Introduction:  It is thought that patients with cardiomyopathy have an increased risk of cardiac arrest on induction of anesthesia, but there is little available data. The purpose of this study was to identify the incidence and potential risk factors for cardiac arrest upon induction of anesthesia in children with cardiomyopathy in our institution.

Parental attitudes to digital recording: A paediatric hospital survey

Aim:  Digital recording is ubiquitous in the community. Its objectivity, permanence and utility in medical education have led to increasing use in health‐care settings. As participants in this process, the perspectives of families are important to inform practice. We surveyed family members of hospitalized children to evaluate their opinions.

Pilot study on the feasibility of limited focused real‐time echocardiography during pediatric renal transplantation

Pediatric renal transplantation protocols describe supraphysiological blood pressure and CVP to optimize graft perfusion. Ideal CVP and blood pressure targets in children are uncertain and difficult to achieve and/or sustain without incurring morbidity. We correlated intra‐operative ECHO with standard monitoring to assess intravascular volume at critical intra‐operative stages. A feasibility pilot study of real‐time limited ECHO images during four critical stages of pediatric renal transplantation (baseline; venous and arterial clamps on; clamps off; 5–10 min post‐clamp release) was conducted. Simultaneous CVP, SBP and DBP measurements were obtained with ECHO images. A surgeon blinded to the ECHO study assessed the quality of graft perfusion. Thirteen patients (nine TTE and four TEE) were enrolled. The CI increased in all patients at vascular clamp removal and the post‐resuscitation period (average increase in CI 20%, range 8–49%). SBP, DBP and CVP were inconsistent. ECHO data confirmed an appropriate CI increase even when the targeted CVP and BP values described in protocols were not achieved. The surgeons were satisfied with graft perfusion in 12 of 13 cases, with one locally obstructed vessel. We suggested that aiming for fixed targets in CVP and BP is not necessary to augment CI and encourage good renal perfusion.