Dominique Biarent Hôpital Universitaire des Enfants Urgences et Soins Intensifs

http://www.c2005.org/presenter.jhtml?identifier=3022512

Your Guide to the 2005 International CoSTR Conference

What is the purpose of the evidence evaluation process?

The

endpoint

of this process is the preparation of the International Consensus on CPR and ECC Science with Treatment Recommendations.

Consensus on Sciences and Treatment Recommendations

What is the purpose of the International CoSTR Conference?

ILCOR is conducting

systematic reviews and updates of scientific evidence

supporting ECC treatment recommendations.

More than 300 CPR and ECC topics scientific will undergo evidence-based review

This process represents the most comprehensive, systematic review of the resuscitation literature to date

Who's in charge?

ILCOR

- the International Liaison Committee on Resuscitation.

includes 7 international resuscitation organizations American Heart Association (AHA), European Resuscitation Council (ERC), Heart and Stroke Foundation of Canada Resuscitation Council of Southern Africa (HSFC), (RCSA), Australia and New Zealand Council on Resuscitation (ANZCOR), InterAmerican Heart Foundation (IAHF). Japan Resuscitation Council JRC : international observer to ILCOR.

China (Ministry of Health) Conference.

: international observer to the C2005

C2005 Evidence Evaluation Worksheets

« Vasopressine leads to better outcome from pediatric cardiac arrest than epinephrine »

Level of Evidence (LOE)

Rating

Direction

Search Strategy

• Vasopressin and cardiac arrest, children, ventricular fibrillation , resuscitation, asystole and children (MeSH term and textwords) • Pubmed 244 hits (19 Aug 2004) • Embase141 hits (19 Aug 2004) • Cochrane Library 1 hit (15 Aug 2004) • Update 24 Jan 2005 : 1 hit

• • • • • • Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.

LOE1 excellent RCT (intention to treat) 1189 patients (no children) Similar rate of survival to hospital admission for VF /PEA Better survival for asystolic patients treated with vasopressin In absence of ROSC with study drug, additional epinephrine improved survival in VP group not in EPI group

Wenzel 2004 VF PEA ASYSTOLE Additional epinephrine w/o ROSC AVP EPI H admission H discharge H admission H discharge H admission H discharge H discharge after epi H discharge Intact neurol 46.2 % 17.8 % 33.7% 5.9 % 29% 4.7% 3.8% 6.2 % 10/40 43% 19.2% 30.5% 8.6 % 20.3% 1.5% 0 1.7 % 4/10 RR –CI 95% 0.9 (0.6-1.3) (p0.48) 1.1 (0.7-1.8) (p0.7) 0.8 (0.5-1.8) (p0.65) 1.4 (0.5-4.7) (p0.47) 0.6 (0.4-0.9) (p0.02*) 0.3 (0.1-1.0) (p0.04*) (p0.008*) 0.3 (0.1-0.6) (p0.002*) (ns)

• Voelckel WG, Lurie KG, McKnite S, et al. Comparison of epinephrine and vasopressin in a pediatric porcine model of asphyxial cardiac arrest. Crit Care Med 2000;28(12):3777-83.

• Paediatric piglet model of asphyxial arrest • Epi or VP+Epi : higher myocardial BF • VP+Epi : higher cerebral BF • ROSC Epi 6/6* VP+Epi 5/6 VP 1/6 • Limitation : use of high dose Epi (200 mcg/kg)

• Voelckel WG, Lurie KG, McKnite S, et al. Effects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation. Crit Care Med 2002;30(5):957-62.

• Paediatric piglet model of prolonged VF (8 min + 20 min CPR), • Combination VP (0.8 IU/kg) +Epi (45 than VP or Epi alone  g/kg) : higher left ventricular myocardial blood flow • VP+Epi and VP alone : higher cerebral blood flow than Epi alone • ROSC ns VP + Epi 6/6 VP5/6 Epi 2/6.

•    Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation 2002;52(2):149-56.

6 long lasting CA in 4 children after > 2 doses adrenaline  VP as rescue therapy 3 ROSC (>1h) 1 withdrawal therapy (>24 h)  1 survivor

High dose versus low dose adrenaline

•

Author A

• « High dose of adrenaline is harmful in children with in-hospital and out-of hospital cardiac arrest » •

Search strategies

• 209 articles excluded • 40 articles analysed : 25 human and 15 animal model studies •

Author B

• « The recommended resuscitation dose of adrenaline for children (0.01 mg/kg) should be increased •

Search strategies

• Age less than 18 years • 5 articles met full criteria

Refractory CA is > 2 doses of adrenaline

• Goetting MG, Paradis NA. High dose epinephrine in refractory pediatric cardiac arrest. Crit Care Med. 1989;17:1258-62 • 7 children received 0.2 mg/kg adre : 6 ROSC Compared to 20 historic controls (SDE): no ROSC • LOE 5 (fair) • Goetting MG, Paradis NA. High-dose epinephrine improves outcome from pediatric cardiac arrest. Ann Emerg Med. 1991;20:22-6.

• Prospective intervention group versus historic control group (20 in each). HDE : 14 ROSC (70%), 8 long term survival, 3 intact • LOE 3

• No difference in survival at discharge • LOE1 (excellent)

Compression / Ventilation Ratio

• Author A • A universal compression ventilation ratio should be used for infants and children irrespective of their age, etiology of arrest and number of rescuers •

Search strategies

• 9 articles • Author B • Scientific evidence supports the superiority of a 5:1 CV ratio in children rather than the 15:2 CV ratio recommended for adults •

Search strategies

• 20 articles used for discussion • 9 articles in grid

In children

• Metabolic rates, CO2 production, ventilatory needs are higher in the non arrest setting • Pediatric CA are precipitated by asphyxia or shock • In-hospital HCP are accustomed to a 5:1 rather than 15:2 • time to BLS in asphyxial CA vs Time to defibrillation in VF are crucial

• Rescue breathing is critically important for asphyxial arrest (inadequate O2 content and high CO2 in the lungs at the time of CA) but not necessary for VF • VF has a normal O2 / CO2 content in lungs and hyperventilation is deleterious • BLS not necessary fort short duration VF • BLS crucial for prolonged duration VF

Evidence Of Science • Manikin studies or animal studies (LOE 6) • Mathematical model (LOE 6)

• Berg RA, Sanders AB et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for VF cardiac arrest. Circ 2001;104:2465-2470 • Interrupting CC for rescue breathing decreases mean coronary perfusion, LV blood flow & number of compression in swine.

• Dorph E, Wik L, Steen PA. Effectiveness of ventilation-compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation. Resuscitation. 2002;54:259-64 • 1 lay rescuer – child sized manikin – 2 ratios 5:1 or 15:2 • Same minute ventilation; Better compression with 15:2

C/V ratios 5:1 10:2 15:2 Tidal volume 121 117 115 Breaths/min 18 17 12 MV 2.2

2.0

1.4

Total compressions/min % effective chest compression 87.9

84.6

78.9

84.6

83.7

84.6

Kinney SB, Tibballs J.

An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression –ventilation ratios in manikin simulated paediatric resuscitation.

Resuscitation 2000;43:115-120.

Mean number of correct compression Min 1 Min 2 Min 3 Min 4 Min 5 Ratio 5/1 58 55 53 60 56 Ratio 15/2 59 41 40 47 34

J. L. Greingor. Quality of cardiac massage with ratio compression –ventilation 5/1 and 15/2.

Resuscitation 2002; 55:263-267

• Babbs CF, Nadkarni V.

Optimizing chest compression to rescue ventilation ratios during one rescuer CPR by professionals and lay persons: children are not just little adults

. Resuscitation 2004;61:173-81.

Optimum C/V ratios in pediatric basic life support 5 + AGE for Pro 5 + AGE/2 for LAY

DO2 Blood flow Alv O2 DO2 Blood flow Alv O2 Oxygen delivery function of C/V ratio (a) professionally trained rescuers (2 rescue breaths in 5 s) (b) lay rescuers, (2 rescue breaths in 16 s) Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical conditions: a physiological and mathematical analysis. Resuscitation. 2002 Aug;54(2):147-57.

Optimal combined flow/DO2

For 10 000 simulations

OPTIMAL RATIO between 30:2 and 50:2

• Simplicity of teaching is crucial • Do we need an universal ratio?

Biphasic defibrillation

Number of shocks that failed to terminate the initial VF episode for monophasic weight based and attenuated adult biphasic shocks in the 4, 14 and 24 kg weight categories. *

P

<0.01.

ROSC and 4 & 24 h survival

Berg RA, Chapman FW et al

Attenuated adult biphasic shocks compared with weight-based monophasic shocks in a swine model of prolonged pediatric ventricular fibrillation.

Resuscitation 2004, 61:

189-197

Ventricular function

Automated External Defibrillator (AED)

• Evaluates the victim’s ECG • Determines if a “shockable” rhythm is present • Charges the “appropriate” dose • When activated by operator, delivers a shock • Provides synthetised voice prompts to assist the operator

AED in children?

• • Experience limited • Recommended (Class IIb) for children older than 1 year in the pre-hospital setting (circulation 2003)

Remember:

– Most arrests in children are respiratory in origin – The most frequent arrest rhythms are Asystole and PEA – Prompt defibrillation is the definitive treatment for VF and pulseless VT – Basic life support sequence

Conclusion

• Ongoing process • Evidence of science • Guidelines • Courses • Evidence Based Medicine