Ting-Chang Hsieh

A quantitative comparison of physiologic indicators of cardiopulmonary resuscitation quality: Diastolic blood pressure versus end-tidal carbon dioxide

AIM The American Heart Association (AHA) recommends monitoring invasive arterial diastolic blood pressure (DBP) and end-tidal carbon dioxide (ETCO2) during cardiopulmonary resuscitation (CPR) when available. In intensive care unit patients, both may be available to the rescuer. The objective of this study was to compare DBP vs. ETCO2 during CPR as predictors of cardiac arrest survival. METHODS In two models of cardiac arrest (primary ventricular fibrillation [VF] and asphyxia-associated VF), 3-month old swine received either standard AHA guideline-based CPR or patient-centric, BP-guided CPR. Mean values of DBP and ETCO2 in the final 2min before the first defibrillation attempt were compared using receiver operating characteristic curves (area under curve [AUC] analysis). The optimal DBP cut point to predict survival was derived and subsequently validated in two independent, randomly generated cohorts. RESULTS Of 60 animals, 37 (61.7%) survived to 45min. DBP was higher in survivors than in non-survivors (40.6±1.8mmHg vs. 25.9±2.4mmHg; p<0.001), while ETCO2 was not different (30.0±1.5mmHg vs. 32.5±1.8mmHg; p=0.30). By AUC analysis, DBP was superior to ETCO2 (0.82 vs. 0.60; p=0.025) in discriminating survivors from non-survivors. The optimal DBP cut point in the derivation cohort was 34.1mmHg. In the validation cohort, this cut point demonstrated a sensitivity of 0.78, specificity of 0.81, positive predictive value of 0.64, and negative predictive value of 0.89 for survival. CONCLUSIONS In both primary and asphyxia-associated VF porcine models of cardiac arrest, DBP discriminates survivors from non-survivors better than ETCO2. Failure to attain a DBP >34mmHg during CPR is highly predictive of non-survival.

A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival

AIM Most pediatric in-hospital cardiac arrests (IHCAs) occur in ICUs where invasive hemodynamic monitoring is frequently available. Titrating cardiopulmonary resuscitation (CPR) to the hemodynamic response of the individual improves survival in preclinical models of adult cardiac arrest. The objective of this study was to determine if titrating CPR to systolic blood pressure (SBP) and coronary perfusion pressure (CoPP) in a pediatric porcine model of asphyxia-associated ventricular fibrillation (VF) IHCA would improve survival as compared to traditional CPR. METHODS After 7min of asphyxia followed by VF, 4-week-old piglets received either hemodynamic-directed CPR (HD-CPR; compression depth titrated to SBP of 90mmHg and vasopressor administration to maintain CoPP ≥20mmHg); or Standard Care (compression depth 1/3 of the anterior-posterior chest diameter and epinephrine every 4min). All animals received CPR for 10min prior to the first defibrillation attempt. CPR was continued for a maximum of 20min. Protocolized intensive care was provided to all surviving animals for 4h. The primary outcome was 4-h survival. RESULTS Survival rate was greater with HD-CPR (12/12) than Standard Care (6/10; p=0.03). CoPP during HD-CPR was higher compared to Standard Care (point estimate +8.1mmHg, CI95: 0.5-15.8mmHg; p=0.04). Chest compression depth was lower with HD-CPR than Standard Care (point estimate -14.0mm, CI95: -9.6 to -18.4mm; p<0.01). Prior to the first defibrillation attempt, more vasopressor doses were administered with HD-CPR vs. Standard Care (median 5 vs. 2; p<0.01). CONCLUSIONS Hemodynamic-directed CPR improves short-term survival compared to standard depth-targeted CPR in a porcine model of pediatric asphyxia-associated VF IHCA.

Tracheal intubation during pediatric cardiopulmonary resuscitation: A videography-based assessment in an emergency department resuscitation room☆

OBJECTIVES To describe procedural characteristics of tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) in a pediatric emergency department, and to characterize interruptions in CPR associated with TI performance. METHODS Retrospective single center case series. Resuscitations in a pediatric ED are videorecorded for quality improvement. Children who underwent TI while receiving chest compressions were eligible for inclusion. Intubations done by methods other than direct laryngoscopy were excluded. Background data included patient age and training background of intubator. Data on intubation attempts (success, laryngoscopy time) and chest compressions (interruptions, duration of pauses) were collected. RESULTS Between December 2012 and February 2014, 32 patients had 59 TI attempts performed during CPR. Overall first attempt success at TI was 15/32 (47%); a median of 2 attempts were made per patient (range 1 to 4). Median laryngoscopy time was 47s (range 8-115s). 32/59 (54%) TI attempts had an associated interruption in CPR; the median interruption duration was 25s (range 3-64s). TI attempts without interruption in CPR were successful in 20/32 (63%) compared to 11/27 (41%) when CPR was paused (p=0.09). Laryngoscopy time was not significantly different between TI attempts with (47±21s) and without (47±26s; p=0.2) interruptions in compressions. 25/32 (78%) of pauses exceeded 10s in duration. CONCLUSIONS TI during pediatric CPR results in significant interruptions in chest compressions. Procedural outcomes were not significantly different between attempts with and without compressions paused. In children receiving CPR, TI should be performed without pausing chest compressions.

43: DESATURATION DURING TRACHEAL INTUBATIONS IN PICUS IS PERVASIVE AND ASSOCIATED WITH ADVERSE OUTCOMES

Learning Objectives: The occurrence of desaturation during tracheal Intubations (TI) and the relation to indication and adverse TI associated events (TIAEs) across diverse Pediatric ICUs (PICUs) is unknown. Methods: Data from a multicenter TI database (NEAR4KIDS) across 31 PICUs from 1/2012-12/2014. All primary TIs with SpO2>90% after pre-oxygenation were included. TI indications were classified as: Respiratory (R), Hemodynamic (H), Respiratory+Hemodynamic (RH), or other (O). We defined moderate desaturation as SpO2 <80% and profound desaturation as SpO2 <70% during TI. We evaluated the association between moderate/profound desaturation with occurrence of any adverse TIAEs or severe TIAEs as well as number of attempts on the occurrence of moderate/ profound desaturation. Analysis was by χ2 and multivariate logistic regression. Results: Of 5,754 TIs, moderate desaturation was associated with TI indications: R 22% (755/3357), H 12% (44/359), RH 28% (94/341), O 11% (185/1697), p<0.001. The association of profound desaturation with TI indication were R 16%, H 8%, RH 20%, O 7%, p<0.001. TIs with moderate desaturation (SpO2< 80%), compared to those without, were associated with TIAEs (32% vs. 13%, p<0.001) and severe TIAEs (11% vs. 5%, p<0.001). Profound desaturation (SpO2<70%) was associated with TIAEs (36% vs.13%, p<0.001) and severe TIAEs (12% vs.5%, p<0.001). All findings persisted after adjusting for TI indications (i.e. severe TIAEs OR: 1.9, 95%CI 1.5–2.4 for moderate desaturation, OR: 2.4, 95%CI 1.8–3.1, for profound desaturation). The number of attempts required for a given TI was associated with moderate and profound desaturation (p<0.001). After adjusting for indication, the associations with moderate desaturation were: 2 attempts OR 3.4 (95%CI 2.9–4.0) and 3+ attempts OR 6.7 (95%CI 5.6–8.0), compared with 1 attempt. For profound desaturation the associations were: 2 attempts OR 3.7, 95%CI 3.0–4.5, and 3+ attempts OR 6.9, 95%CI 5.6–8.5. Conclusions: Moderate (SpO2<80%) and profound (SpO2<70%) desaturations are associated with TIAEs. Number of TI attempts is also associated with desaturation during TI.

Improving Outcomes of Critically Ill Children With Simulation-Based Education: Where Are We Now in the Year 2016?

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