Pediatric In-Hospital Cardiac Arrest International Registry (PACHIN): protocol for a prospective international multicenter register of cardiac arrest in children.

BACKGROUND AND AIMS: Cardiac arrest (CA) in children is a major public health problem. Thanks to advances in cardiopulmonary resuscitation (CPR) guidelines and teaching skills, results in children have improved. However, pediatric CA has a very high mortality. In the treatment of in-hospital CA there are still multiple controversies. The objective of this study is to develop a multicenter and international registry of in-hospital pediatric cardiac arrest including the diversity of management in different clinical and social contexts. Participation in this register will enable the evaluation of the diagnosis of CA, CPR and post-resuscitation care and its influence in survival and neurological prognosis. METHODS: An intrahospital CA data recording protocol has been designed following the Utstein model. Database is hosted according to European legislation regarding patient data protection. It is drafted in English and Spanish. Invitation to participate has been sent to Spanish, European and Latinamerican hospitals. Variables included, asses hospital characteristics, the resuscitation team, patient's demographics and background, CPR, post-resuscitation care, mortality, survival and long-term evolution. Survival at hospital discharge will be evaluated as a primary outcome and survival with good neurological status as a secondary outcome, analyzing the different factors involved in them. The study design is prospective, observational registry of a cohort of pediatric CA. CONCLUSIONS: This study represents the development of a registry of in-hospital CA in childhood. Its development will provide access to CPR data in different hospital settings and will allow the analysis of current controversies in the treatment of pediatric CA and post-resuscitation care. The results may contribute to the development of further international recommendations. Trial register: ClinicalTrials.gov Identifier: NCT04675918. Registered 19 December 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04675918?cond=pediatric+cardiac+arrest&draw=2&rank=10.

Use of a Servo-Controlled Cooling Gel Pad System to Regulate Body Temperature in Critically Ill Children.

OBJECTIVES: To assess the efficacy and safety of a servo-controlled cooling pad system for target temperature management in critically ill pediatric patients. DESIGN: A prospective, single-center, observational study. SETTING: PICU of a tertiary hospital from September 2018 to September 2019. PATIENTS: Children from 28 days to 16 years old subjected to servo-controlled body temperature control. METHODS: The Arctic Sun 5000 system (Bard Medical, Covington, GA) and Arctic Gel Hydrogel pads were used for the purposes of the study. Data collected included demographics, indication of therapy, patient's body temperature, target temperature, time-to-target temperature, duration of therapy, and need to start or increase sedation and/or muscle relaxants. MEASUREMENTS AND MAIN RESULTS: A total of 16 patients were included, of whom 68.8% were male; mean age was 4.7 years. The most frequent indication was fever associated with hemodynamic instability (62.5%). The target temperature was normothermia (36 or 36.5°C) in 81% of cases. Mean baseline body temperature was 37.6°C (± 1.2°C), and 50% of patients had fever (> 38°C). The mean speed of cooling was 1.2°C/hr (± 1°C/hr). Mean time to target temperature was 118 minutes (± 98.8 min). Mean duration of therapy was 68.7 hours (± 58.3 hr). Two patients had fever related to device disconnection during the treatment. At the start of the therapy, 15 patients were receiving sedative and analgesic drugs, and four received muscle relaxants. A patient required increased sedation, whereas another patient needed to start muscle relaxants. One of the patients developed a skin lesion in the axilla, no other adverse events were registered. CONCLUSIONS: Despite the small sample size, the results of the study showed that target temperature management by the servo-controlled gel pad system in critically ill pediatric patients was effective in achieving satisfactory temperature control and it was well-tolerated.

Volumetric capnography and return of spontaneous circulation in an experimental model of pediatric asphyxial cardiac arrest.

A secondary analysis of a randomized study was performed to study the relationship between volumetric capnography (VCAP) and arterial CO2 partial pressure (PCO2) during cardiopulmonary resuscitation (CPR) and to analyze the ability of these parameters to predict the return of spontaneous circulation (ROSC) in a pediatric animal model of asphyxial cardiac arrest (CA). Asphyxial CA was induced by sedation, muscle relaxation and extubation. CPR was started 2 min after CA occurred. Airway management was performed with early endotracheal intubation or bag-mask ventilation, according to randomization group. CPR was continued until ROSC or 24 min of resuscitation. End-tidal carbon dioxide (EtCO2), CO2 production (VCO2), and EtCO2/VCO2/kg ratio were continuously recorded. Seventy-nine piglets were included, 26 (32.9%) of whom achieved ROSC. EtCO2 was the best predictor of ROSC (AUC 0.72, p < 0.01 and optimal cutoff point of 21.6 mmHg). No statistical differences were obtained regarding VCO2, VCO2/kg and EtCO2/VCO2/kg ratios. VCO2 and VCO2/kg showed an inverse correlation with PCO2, with a higher correlation coefficient as resuscitation progressed. EtCO2 also had an inverse correlation with PCO2 from minute 18 to 24 of resuscitation. Our findings suggest that EtCO2 is the best VCAP-derived parameter for predicting ROSC. EtCO2 and VCO2 showed an inverse correlation with PCO2. Therefore, these parameters are not adequate to measure ventilation during CPR.

Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest.

To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.

Incidence and pattern of brain lesions in paediatric septic shock patients.

OBJECTIVE: Brain injury is frequently observed during septic shock and may be primarily related to the direct effects of the septic insult on the brain or to secondary/indirect injuries (e.g. hypotension, hypoxaemia and hyperglycaemia). We sought to assess incidence and pattern of brain lesions diagnosed by neuroimaging in paediatric septic shock patients. METHODS: Retrospective descriptive hospital-based study included paediatric patients with a single episode of septic shock admitted to our tertiary paediatric intensive care unit from January 2010 to December 2013. RESULTS: 49 of 193 septic shock patients had a neuroimaging examination [CT only 22 (45%), MRI only 14 (29%) and both 13 (27%)]. Neuroimaging was normal in 16 patients (33%) and showed acute lesions in 20 patients (40%). The most frequent findings were: cerebral infarcts/hypoxic ischaemic injury in 8 (16%) and cerebritis in 7 (14%). The incidence of acute brain lesion in our septic shock cohort was 10% (20 of 193). CONCLUSION: The diagnosis of brain dysfunction in septic shock patients relies essentially on neurological examination and neurological tests, such as electroencephalography and neuroimaging. Neuroimaging can reveal acute intracerebral structural lesions and their reversibility, helping with management and prognosis. Advances in knowledge: Ischaemic lesions and cerebritis are the most common brain anomalies complicating paediatric septic shock.