pediatric resuscitation: what is new and what is old? · 2020-02-11 · medical director...

Pediatric Resuscitation: what is new

and what is old?

Belangenverstrengeling sprekers: GEEN

Nigel Turner

Pediatric cardiac anesthesiologist, WKZ-UMCU

Medical Director SHK-foundation

Scientific committee Dutch Resuscitation Council

Writing group ERC-guidelines 2020No perceived

conflict of interest

2

Case: Laura v.d. Pseudoniem

• 2 mth 3,5 kg

• Syndromal anomaly (not further diagnosed)

• Known difficult airway – previously intubated with Eschmann

• Mask ventilation difficult but possible

• One intubation attempt:

• Can’t intubate, can’t ventilate extreme bradycardia

What now?

3

Casus: Laura v.d. Pseudoniem

4

Contents

• Quiz

• Epidemiology of Perioperative Pediatric Circulatory Arrest (POPCA)

• Current Resuscitation Guidelines

• Some interesting misconceptions

• Q&A

5

Quiz

• 9 questions

• Remember your answers

B NL

6

Question 1

Most circulatory arrests during anesthesia occur during:

A. Induction

B. Maintenance

C. Emergence

7

Question 2

Perioperative circulatory arrest in children has a better prognosis that all in-hospital circulatory arrests combined.

A. True

B. False

8

Question 3

Thorax compressions in an infant are best performed using

A. Twee fingers

B. Two thumbs

C. Either technique

9

Question 4

During a circulatory arrest with a shockable rhythm a defibrillation attempt should always be followed by immediate recommencement of thorax compressions:

A. True

B. False

10

Question 5

Intralipid is recommended in the treatment of local anesthetic toxicity. If Intralipid is not available Propofol can be used.

A. True

B. False

11

Question 6

The minimum dose of atropine in small children is 100 mcg.

A. True

B. False

12

Question 7

The insertion depth of the nasopharyngeal airway is best estimated as the distance from the tip of the nose to the:

A. Angle of the mandibule

B. Tragus of the ear

13

Question 8

The best method to estimate a child’s weight in an emergency is the rule:

A. [Age (yrs) + 4] x 2 [B]

B. [Age (yrs) + 4] x 2.5 [NL]

14

Question 9

I am going to hear all about the new 2020 ERC Pediatric Resuscitation guidelines today.

A. True

B. False

15

New guidelines

• End 2020

• What will change?

• We don’t know yet

16

POPCA

Perioperative Pediatric Circulatory Arrest

17

POPCA

• Definition:

– Thoraxcompression, and /or:

– Death

– Location: OR until discharge from recovery

Turner NM, PhD Thesis University Utrecht 2008

18

Incidence

Anesthesia is safer than ever:

• Mortality 60 x lower than 1959

• Safer drugs, equipment, procedures, monitoring, training and centralisation(?)

Incidence POPCA same as 1994

• Sicker children presented to OR?

191.000 operations / yr in in NL => 20 POPCA/yr

Apricot: 10 POPCA / 30.000 cases all with ROSC, 3 deaths

Pediatric Surgery International 2012 28:553-61Anesthesiology 2000 93:6-14Resuscitation. 2000 45:17-25Apricot study Lancet 2017

1,5

70

550

0,90

100

200

300

400

500

600

POPCA IHPCA PCA op PICU OHPCA / jr

Incidence PCA per 10.000 admissions

19

When does POPCA occur?

Take-off and landing are not the only dangerous moments

0%

20%

40%

60%

(Pre-)Inleiding Onderhoud Uitleiding /recovery

POPCA: Phase of Operation

Paediatr Anaesth. 2013 23:517-23

(Pre-)Induction Maintenance Awakening / recovery

20

Question 1

Most circulatory arrests during anesthesia occur during:

A. Induction

B. Maintenance

C. Emergence

21

Pre-/comorbidity

Paediatr Anaesth. 2013 23:517-23

Healthy: 22%

Cardio: 15%Other comorbidity: 63%

22

Whodunnit?

‘Anesthesia’ 50%

• Medication 18%

• Cardiovascular 41% – Failure to keep up with blood-loss– Hyperkalemia

• Respiratory 27%, – Airway obstruction, laryngospasm

• Equipment and procedures 5%– CVL (2,5%)

Other 50%

• Underlying condition:70% ASA 4+

• Failure to wean from bypass

• Hemorrhage: 17%

• Unknown causes: 25%

Anesth Analg. 2007 105:344-50.

23

Age distribution POPCA

< 1 jr; 30%

1 -5 jr; 37%

> 5 jr; 33%

POPCA: age

Paediatr Anaesth. 2013 23:517-23

24

Outcome POPCA

Predictors of mortality:

• ASA classification

• Emergency procedure

• Night/weekend

• Age is NOT a predictor

Prognosis after IHPCA

MortalityResidual impairmentComplete recovery

(all)

25

Question 2

Perioperative circulatory arrest in children has a better prognosis that all in-hospital circulatory arrests combined.

A. True

B. False

26

Current Resuscitation Guidelines

27

Resuscitation: overview

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

28

Resuscitation: overview

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Difficult!How can you recognizecirculatory arrest under GA?

• Inadequate heart rate • Inadequate arterial blood pressure• Apnea or gasping • Cyanosis or dark blood in wound• Failure of pulse oximetry• Failure of NIBP measurement• Loss of arterial line waveform• Absent or abnormal heart tone• Abrupt decrease in ETCO2

29

PBLS

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Recognition

30

Thorax compressions• 15:2

• 100 – 120 /min

• Lower half of the sternum

• At least one third of the AP-diameter

?

31

Thorax compressions - Baby

32

Thaler - evidence

Advantages

• Deeper compressions

• Higher bloodpressure

• Placement generally better

• Less fatigue

• Rate: no difference overall

Disadvantages

• Hands-off time longer but small difference: 0.6 s or 2 s over 2 min

• 4 fewer compressions/min (NS)

• Slightly less recoil with TT

Lee et al. Medicine (2019) 98:45Douvanas er al J Matern Fetal Neonatal Med. 2018 31:805-16

33

Question 3

Thorax compressions in an infant are best performed using

A. Twee fingers

B. Two thumbs

C. Either technique

34

Thorax compressions - Child

35

CPR in the prone position

Shaffner et al: Pediatric Perioperative Life Support Anesth Analg 2013;117:960–79

36

PBLS –most common faults

1. Starting compressions too late

2. Interrupting compressions

3. Not changing roles – compressions > 2 min

4. …………………………………………Fill in your own personal pitfall here

37

p-ALS

Shaffner et al: Pediatric Perioperative Life Support Anesth Analg 2013;117:960–79

38

Check ECG

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

39

Choose and follow correct algorithm

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

40

Non-shockable

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

41

Non-shockable

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Rhythm check 2 min

Adrenaline 4 min

42

Shockable

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

43

Shockable

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Immediately resume: BLS for 2 min

minimize interruptions

Assess Rhythm

1 Shock

• 4 J/kg manual• Preferably paed-AED <8yr

44

Shockable

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Immediately resume: BLS for 2 min

minimize interruptions

Assess Rhythm

Adrenaline after 4 mins

Shock every 2 mins

1 Shock

• 4 J/kg manual• Preferably paed-AED <8yr

45

Shockable

Charge, rhythm check, defibrillate

46

Witnessed arrest in VF/pVT

47

Witnessed arrest in VF/pVT

Witnessed arrest: ‘immediate defibrillation’ possible

48

Witnessed arrest in VF/pVT

Witnessed arrest: ‘immediate defibrillation’ possible

49

Witnessed arrest in VF/pVT

Witnessed arrest: ‘immediate defibrillation’ possible

50

Witnessed arrest in VF/pVT

CPR

Witnessed arrest: ‘immediate defibrillation’ possible

51

Witnessed arrest in VF/pVT

CPR

Witnessed arrest: ‘immediate defibrillation’ possible

52

Witnessed arrest in VF/pVT

CPR

Amiodaron?

Witnessed arrest: ‘immediate defibrillation’ possible

53

Witnessed arrest in VF/pVT

CPR

Witnessed arrest: ‘immediate defibrillation’ possible

54

Witnessed arrest in VF/pVT

CPR

Adrenaline?

Witnessed arrest: ‘immediate defibrillation’ possible

55

Witnessed arrest in VF/pVT

Witnessed arrest: ‘immediate defibrillation’ possible

CPR

56

Question 4

During a circulatory arrest with a shockable rhythm a defibrillation attempt should always be followed by immediate recommencement of thorax compressions:

A. True

B. False

57

p-ALS most common faults

1. Failure to recognize PEA under anesthesia

2. Fixation on the airway and no compressions

3. Following the algorithm without thinking of the cause

4. …………………………………………Fill in your personal pitfall here

58

Look for the cause

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

59

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Look for the cause

Reversible causes• Hypoxia• Hypovolemia• Hypo/hyperkalemia (etc)• Hypothermia• Tension pneumothorax• Tamponade• Toxins• Thrombo-embolism

60

Recognize CA

Uninterrupted PBLS

ECGShockable /non-shockable

p-ALS:Follow correct algorithm

Look for and treat the CAUSE

Reversible causes• Hypoxia• Hypovolemia• Hypo/hyperkalemia (etc)• Hypothermia• Tension pneumothorax• Tamponade• Toxins• Thrombo-embolism

Look for the cause

Raised ICP - drain dysfunction

Massive transfusion or Tranfusion reaction

Mediastinal massHigh PEEP

LA toxicity

Air/ gas / amniotic fluid

Total spinalAnaphylaxis

61

Some interesting misconceptions

62

Intoxication LA

Presentation

• Agitation, confusion, convulsion etc

• ECG:– Prolonged PR

– Bradycardia

– AV- block

• Hypotension

Treatment

• Convulsions: benzo’s or propofol

• Antiarrhythmic: amiodaron - NO LIDO!

Intralipid 20% (NOT propofol!):

• 1,5 mL/kg in 1 min + 2,5 mL/kg/min over 10 min

• If no response: 1,5 mL/kg bolus + 5 mL/kg over 10 min

63

Propofol vs Intralipid

INTRALIPID 20% PROPOFOL 1%

Glycerin 2.25% 2.25%

Egg Yolk Phospholipids 1.2%, 1.2%,

Soyabean oil 20% 20%

Propofol 0 10 mg/kg

64

Question 5

Intralipid is recommended in the treatment of local anesthetic toxicity. If Intralipid is not available Propofol can be used.

A. True

B. False

65

Atropine

Eisa, Arch Dis Child. 2015 100:684-8

66

Effect atropine under GA

• Controlled observational study

• < 15 kg (age 6.5 (4-12) mth; weight 8.6 (8.1-9.1) kg)

• N2O/O2/sevo

• Atropine 5 mcg/kg IV

• HR increased, NO Bradycardia

• Insignificant PAC’s/PVC’s

Eisa, Arch Dis Child. 2015 100:684-8

67

Effect atropine under GA

Eisa, Arch Dis Child. 2015 100:684-8

HR

68

It’s a myth !

Barrington 2011 Pediatrics 127:783-4

69

Atropine dose

Dauchot & Gravenstein Clin Pharmacol Ther. 1971 12:274

70

Question 6

The minimum dose of atropine in small children is 100 mcg.

A. True

B. False

71

Nasopharyngeal airway

72

Nasopharyngeal airway

• 160 3-D MRI-scans children < 12 yr

• Measurement of distances:

– nares-tragus

– nares-mandible

– nares-epiglottis

Johnson: Resuscitation. 2019 140:50-4

73

Nasopharyngeal airway

Johnson: Resuscitation. 2019 140:50-4

CONCLUSION: use nares-tragus minus 1 cm

Nose-tragus

Nose-mandibule

No

se-e

pig

lott

is

Landmark distance

74

Question 7

The insertion depth of the nasopharyngeal airway is best estimated as the distance from the tip of the nose to the:

A. Angle of the mandibule

B. Tragus of the ear

75

Reliability weight estimation methods

Wells, 2017 Int J Emerg Med 10:29.

BT = Broselow Tape

76

Question 8

The best method to estimate a child’s weight in an emergency is the rule:

A. [Age (yrs) + 4] x 2 [B]

B. [Age (yrs) + 4] x 2.5 [NL]

77

Conclusions

• Resuscitation is more than following a protocol

– There is more to life than ABC

• A number of resuscitation myths are a-bustin’

• Look out for the new ERC-guidelines 2020

78

Ineresting papers

• Shaffner, Anesth Analg 2013 117:960–79 PediatricPerioperative Life Support

• Lee. (2019) Medicine 98:45 Two fingers / two thumbs

• Barrington, Pediatrics 2011 127:783-4 Myth of atropine

• Wells, Int J Emerg Med 2017 10:29. Broselow tape vs othermethods.

• Christensen, Paediatr Anaesth 2013 23:517 CA in de PCA. AHA Get With The Guidelines-Resuscitation registry.

79

80

81

Aanbeveling 3

• Cardiac arrest/CPR in buikligging

• Het kan!!!

• Wei. J Chin Med Assoc 2006– Part 1 – circulation

– 11 overleden ptn (IC)

– CPR in rugligging vs CPR in buikligging

– BP 55/13 (SD 20/7) mmHg vs 79/17 (SD 20/10) mmHg (p = 0.028)

82

CPR in prone position - vervolg

• Wei. J Chin Med Assoc 2006– Part 2 – ventilation

– 10 healthy volunteers

– Prone position

– Compression on back

– VT 399 (SD 110) mL

• C/ Our study revealed that prone CPR provides good respiratory and circulatory support at the same time

83

CPR in prone position

• Mazer SP Resuscitation 2003– 6 pts in ICU that failed CPR for 30 min– Additional 30 min of CPR, 15’ supine, 15’ prone– Mean SBP from 48 > 72 (+23, SD 10) – Mean MAP 32 > 46 (+14, SD 11)– Mean DBP 24 > 34 (+10, SD 12)– No patient had ROSC

• C/ Reverse CPR generates higher mean SBP and higher mean MAP during circulatory arrest than standard CPR