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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
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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?
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Casus: Laura v.d. Pseudoniem
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Contents
• Quiz
• Epidemiology of Perioperative Pediatric Circulatory Arrest (POPCA)
• Current Resuscitation Guidelines
• Some interesting misconceptions
• Q&A
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Quiz
• 9 questions
• Remember your answers
B NL
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Question 1
Most circulatory arrests during anesthesia occur during:
A. Induction
B. Maintenance
C. Emergence
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Question 2
Perioperative circulatory arrest in children has a better prognosis that all in-hospital circulatory arrests combined.
A. True
B. False
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Question 3
Thorax compressions in an infant are best performed using
A. Twee fingers
B. Two thumbs
C. Either technique
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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
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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
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Question 6
The minimum dose of atropine in small children is 100 mcg.
A. True
B. False
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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
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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]
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Question 9
I am going to hear all about the new 2020 ERC Pediatric Resuscitation guidelines today.
A. True
B. False
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New guidelines
• End 2020
• What will change?
• We don’t know yet
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POPCA
Perioperative Pediatric Circulatory Arrest
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POPCA
• Definition:
– Thoraxcompression, and /or:
– Death
– Location: OR until discharge from recovery
Turner NM, PhD Thesis University Utrecht 2008
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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
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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
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Question 1
Most circulatory arrests during anesthesia occur during:
A. Induction
B. Maintenance
C. Emergence
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Pre-/comorbidity
Paediatr Anaesth. 2013 23:517-23
Healthy: 22%
Cardio: 15%Other comorbidity: 63%
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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.
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Age distribution POPCA
< 1 jr; 30%
1 -5 jr; 37%
> 5 jr; 33%
POPCA: age
Paediatr Anaesth. 2013 23:517-23
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Outcome POPCA
Predictors of mortality:
• ASA classification
• Emergency procedure
• Night/weekend
• Age is NOT a predictor
Prognosis after IHPCA
MortalityResidual impairmentComplete recovery
(all)
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Question 2
Perioperative circulatory arrest in children has a better prognosis that all in-hospital circulatory arrests combined.
A. True
B. False
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Current Resuscitation Guidelines
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Resuscitation: overview
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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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
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PBLS
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
Recognition
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Thorax compressions• 15:2
• 100 – 120 /min
• Lower half of the sternum
• At least one third of the AP-diameter
?
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Thorax compressions - Baby
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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
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Question 3
Thorax compressions in an infant are best performed using
A. Twee fingers
B. Two thumbs
C. Either technique
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Thorax compressions - Child
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CPR in the prone position
Shaffner et al: Pediatric Perioperative Life Support Anesth Analg 2013;117:960–79
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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
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p-ALS
Shaffner et al: Pediatric Perioperative Life Support Anesth Analg 2013;117:960–79
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Check ECG
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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Choose and follow correct algorithm
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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Non-shockable
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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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
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Shockable
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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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
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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
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Shockable
Charge, rhythm check, defibrillate
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Witnessed arrest in VF/pVT
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Witnessed arrest in VF/pVT
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
CPR
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
CPR
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
CPR
Amiodaron?
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
CPR
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
CPR
Adrenaline?
Witnessed arrest: ‘immediate defibrillation’ possible
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Witnessed arrest in VF/pVT
Witnessed arrest: ‘immediate defibrillation’ possible
CPR
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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
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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
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Look for the cause
Recognize CA
Uninterrupted PBLS
ECGShockable /non-shockable
p-ALS:Follow correct algorithm
Look for and treat the CAUSE
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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
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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
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Some interesting misconceptions
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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
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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
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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
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Atropine
Eisa, Arch Dis Child. 2015 100:684-8
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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
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Effect atropine under GA
Eisa, Arch Dis Child. 2015 100:684-8
HR
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It’s a myth !
Barrington 2011 Pediatrics 127:783-4
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Atropine dose
Dauchot & Gravenstein Clin Pharmacol Ther. 1971 12:274
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Question 6
The minimum dose of atropine in small children is 100 mcg.
A. True
B. False
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Nasopharyngeal airway
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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
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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
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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
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Reliability weight estimation methods
Wells, 2017 Int J Emerg Med 10:29.
BT = Broselow Tape
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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]
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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
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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.
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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)
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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
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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