RESUMO
AIM: To examine the relationship between survival and diastolic blood pressure (DBP) throughout resuscitation from paediatric asphyxial cardiac arrest. METHODS: Retrospective, secondary analysis of 200 swine resuscitations. Swine underwent asphyxial cardiac arrest and were resuscitated with predefined periods of basic and advanced life support (BLS and ALS, respectively). DBP was recorded every 30â¯s. Survival was defined as 20-min sustained return of spontaneous circulation (ROSC). RESULTS: During BLS, DBP peaked between 1-3â¯min and was greater in survivors (20.0 [11.3, 33.3] mmHg) than in non-survivors (5.0 [1.0, 10.0] mmHg; pâ¯<â¯0.001). After this transient increase, the DBP in survivors progressively decreased but remained greater than that of non-survivors after 10 min of resuscitation (9.0 [6.0, 13.8] versus 3.0 [1.0, 6.8] mmHg; pâ¯<â¯0.001). During ALS, the magnitude of DBP change after the first adrenaline (epinephrine) administration was greater in survivors (22.0 [16.5, 36.5] mmHg) than in non-survivors (6.0 [2.0, 11.0] mmHg; pâ¯<â¯0.001). Survival rate was greater when DBP improved by ≥26â¯mmHg after the first dose of adrenaline (20/21; 95%) than when DBP improved by ≤10â¯mmHg (1/99; 1%). The magnitude of DBP change after the first adrenaline administration correlated with the timetoROSC (râ¯=â¯-0.54; pâ¯<â¯0.001). CONCLUSIONS: Survival after asphyxial cardiac arrest is associated with a higher DBP throughout resuscitation, but the difference between survivors and non-survivors was reduced after prolonged BLS. During ALS, response to adrenaline administration correlates with survival and time to ROSC. If confirmed clinically, these findings may be useful for titrating adrenaline during resuscitation and prognosticating likelihood of ROSC. Institutional Protocol Numbers: SW14M223 and SW17M101.
Assuntos
Asfixia/complicações , Pressão Sanguínea/fisiologia , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/fisiopatologia , Animais , Asfixia/fisiopatologia , Asfixia/terapia , Diástole , Modelos Animais de Doenças , Seguimentos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , SuínosRESUMO
OBJECTIVES: To determine the effect of the duration of asphyxial arrest on the survival benefit previously seen with end-tidal CO2-guided chest compression delivery. DESIGN: Preclinical randomized controlled study. SETTING: University animal research laboratory. SUBJECTS: Two-week-old swine. INTERVENTIONS: After either 17 or 23 minutes of asphyxial arrest, animals were randomized to standard cardiopulmonary resuscitation or end-tidal CO2-guided chest compression delivery. Standard cardiopulmonary resuscitation was optimized by marker, monitor, and verbal feedback about compression rate, depth, and release. End-tidal CO2-guided delivery used adjustments to chest compression rate and depth to maximize end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation for both groups proceeded from 10 minutes of basic life support to 10 minutes of advanced life support or return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS: After 17 minutes of asphyxial arrest, mean end-tidal CO2 during 10 minutes of cardiopulmonary resuscitation was 18 ± 9 torr in the standard group and 33 ± 15 torr in the end-tidal CO2 group (p = 0.004). The rate of return of spontaneous circulation was three of 14 (21%) in the standard group rate and nine of 14 (64%) in the end-tidal CO2 group (p = 0.05). After a 23-minute asphyxial arrest, neither end-tidal CO2 values (20 vs 26) nor return of spontaneous circulation rate (3/14 vs 1/14) differed between the standard and end-tidal CO2-guided groups. CONCLUSIONS: Our previously observed survival benefit of end-tidal CO2-guided chest compression delivery after 20 minutes of asphyxial arrest was confirmed after 17 minutes of asphyxial arrest. The poor survival after 23 minutes of asphyxia shows that the benefit of end-tidal CO2-guided chest compression delivery is limited by severe asphyxia duration.
Assuntos
Asfixia/fisiopatologia , Asfixia/terapia , Circulação Sanguínea , Dióxido de Carbono/análise , Reanimação Cardiopulmonar/métodos , Animais , Animais Recém-Nascidos , Pressão Arterial , Asfixia/sangue , Gasometria , Capnografia , Dióxido de Carbono/sangue , Diástole , Modelos Animais de Doenças , Retroalimentação , Masculino , Monitorização Fisiológica , Distribuição Aleatória , Suínos , Fatores de TempoRESUMO
OBJECTIVES: To determine whether end-tidal CO2-guided chest compression delivery improves survival over standard cardiopulmonary resuscitation after prolonged asphyxial arrest. DESIGN: Preclinical randomized controlled study. SETTING: University animal research laboratory. SUBJECTS: 1-2-week-old swine. INTERVENTIONS: After undergoing a 20-minute asphyxial arrest, animals received either standard or end-tidal CO2-guided cardiopulmonary resuscitation. In the standard group, chest compression delivery was optimized by video and verbal feedback to maintain the rate, depth, and release within published guidelines. In the end-tidal CO2-guided group, chest compression rate and depth were adjusted to obtain a maximal end-tidal CO2 level without other feedback. Cardiopulmonary resuscitation included 10 minutes of basic life support followed by advanced life support for 10 minutes or until return of spontaneous circulation. MEASUREMENTS AND MAIN RESULTS: Mean end-tidal CO2 at 10 minutes of cardiopulmonary resuscitation was 34 ± 8 torr in the end-tidal CO2 group (n = 14) and 19 ± 9 torr in the standard group (n = 14; p = 0.0001). The return of spontaneous circulation rate was 7 of 14 (50%) in the end-tidal CO2 group and 2 of 14 (14%) in the standard group (p = 0.04). The chest compression rate averaged 143 ± 10/min in the end-tidal CO2 group and 102 ± 2/min in the standard group (p < 0.0001). Neither asphyxia-related hypercarbia nor epinephrine administration confounded the use of end-tidal CO2-guided chest compression delivery. The response of the relaxation arterial pressure and cerebral perfusion pressure to the initial epinephrine administration was greater in the end-tidal CO2 group than in the standard group (p = 0.01 and p = 0.03, respectively). The prevalence of resuscitation-related injuries was similar between groups. CONCLUSIONS: End-tidal CO2-guided chest compression delivery is an effective resuscitation method that improves early survival after prolonged asphyxial arrest in this neonatal piglet model. Optimizing end-tidal CO2 levels during cardiopulmonary resuscitation required that chest compression delivery rate exceed current guidelines. The use of physiologic feedback during cardiopulmonary resuscitation has the potential to provide optimized and individualized resuscitative efforts.
Assuntos
Asfixia/terapia , Capnografia , Dióxido de Carbono/metabolismo , Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Massagem Cardíaca/métodos , Animais , Asfixia/complicações , Asfixia/metabolismo , Asfixia/mortalidade , Biomarcadores/metabolismo , Reanimação Cardiopulmonar/mortalidade , Parada Cardíaca/etiologia , Parada Cardíaca/metabolismo , Parada Cardíaca/mortalidade , Massagem Cardíaca/mortalidade , Humanos , Masculino , Estudo de Prova de Conceito , Distribuição Aleatória , Taxa de Sobrevida , Suínos , Resultado do TratamentoRESUMO
Williams syndrome (WS) is a congenital, multisystem disorder affecting the cardiovascular, connective tissue, and central nervous systems in 1 in 10 000 live births. Cardiovascular involvement is the most common cause of morbidity and mortality in patients with WS, and noninvasive and invasive procedures are common. Sudden cardiovascular collapse in patients with WS is a well-known phenomenon, especially in the peri-procedural period. Detailed guidelines for peri-procedural management of patients with WS are limited. The goal of this review is to provide thoughtful, safe and effective management strategies for the peri-procedural care of patients with WS with careful consideration of hemodynamic impacts of anesthetic strategies. In addition, an expanded risk stratification system for anesthetic administration is provided.
Assuntos
Anestesia/métodos , Sistema Cardiovascular/fisiopatologia , Morte Súbita Cardíaca/prevenção & controle , Hemodinâmica , Choque/prevenção & controle , Síndrome de Williams/terapia , Anestesia/efeitos adversos , Morte Súbita Cardíaca/etiologia , Humanos , Medição de Risco , Fatores de Risco , Choque/etiologia , Choque/mortalidade , Choque/fisiopatologia , Resultado do Tratamento , Síndrome de Williams/complicações , Síndrome de Williams/mortalidade , Síndrome de Williams/fisiopatologiaRESUMO
BACKGROUND: End-tidal carbon dioxide (ETCO2) correlates with systemic blood flow and resuscitation rate during cardiopulmonary resuscitation (CPR) and may potentially direct chest compression performance. We compared ETCO2-directed chest compressions with chest compressions optimized to pediatric basic life support guidelines in an infant swine model to determine the effect on rate of return of spontaneous circulation (ROSC). METHODS AND RESULTS: Forty 2-kg piglets underwent general anesthesia, tracheostomy, placement of vascular catheters, ventricular fibrillation, and 90 seconds of no-flow before receiving 10 or 12 minutes of pediatric basic life support. In the optimized group, chest compressions were optimized by marker, video, and verbal feedback to obtain American Heart Association-recommended depth and rate. In the ETCO2-directed group, compression depth, rate, and hand position were modified to obtain a maximal ETCO2 without video or verbal feedback. After the interval of pediatric basic life support, external defibrillation and intravenous epinephrine were administered for another 10 minutes of CPR or until ROSC. Mean ETCO2 at 10 minutes of CPR was 22.7±7.8 mm Hg in the optimized group (n=20) and 28.5±7.0 mm Hg in the ETCO2-directed group (n=20; P=0.02). Despite higher ETCO2 and mean arterial pressure in the latter group, ROSC rates were similar: 13 of 20 (65%; optimized) and 14 of 20 (70%; ETCO2 directed). The best predictor of ROSC was systemic perfusion pressure. Defibrillation attempts, epinephrine doses required, and CPR-related injuries were similar between groups. CONCLUSIONS: The use of ETCO2-directed chest compressions is a novel guided approach to resuscitation that can be as effective as standard CPR optimized with marker, video, and verbal feedback.
Assuntos
Dióxido de Carbono/metabolismo , Reanimação Cardiopulmonar/métodos , Expiração , Parada Cardíaca/terapia , Hemodinâmica , Monitorização Fisiológica/métodos , Respiração Artificial , Fatores Etários , Animais , Animais Recém-Nascidos , Percepção Auditiva , Biomarcadores/metabolismo , Testes Respiratórios , Capnografia , Modelos Animais de Doenças , Retroalimentação Psicológica , Parada Cardíaca/diagnóstico , Parada Cardíaca/metabolismo , Parada Cardíaca/fisiopatologia , Valor Preditivo dos Testes , Suínos , Análise e Desempenho de Tarefas , Fatores de Tempo , Gravação em Vídeo , Percepção VisualRESUMO
BACKGROUND: Thermal epiglottitis is a rare but potentially life-threatening disease. Diagnosis requires a thorough history and high clinical level of suspicion, particularly in children. Thermal epiglottitis from steam inhalation can have a slow onset without oropharyngeal signs of thermal injury, findings that can hide the clinical diagnosis. OBJECTIVE: Our aim was to review the pathophysiology and clinical presentation of thermal epiglottitis and the challenges involved in diagnosis and management of this form of atypical epiglottitis. CASE REPORT: We describe the case of a 22-month-old male presenting to the pediatric emergency department after a scald burn from steam and boiling water resulting in 12% body surface area burns to his chin, chest, and shoulder, with no obvious oropharyngeal or neck injuries. At the time of presentation, he was afebrile and well appearing. Six hours after the injury, he was sitting in the "tripod position," drooling, with pooled saliva in his mouth and inspiratory stridor. Intubation in the operating room using conventional direct laryngoscopy was not successful and he was intubated using an operative endoscope. Laryngoscopy demonstrated thermal epiglottitis. A tracheostomy was performed to secure the airway, and he was admitted to the pediatric intensive care unit. He was discharged home and decannulated 4 weeks later, when airway endoscopy showed complete recovery with normal airway structures. CONCLUSION: A thorough history and physical examination together with a high level of suspicion and aggressive, collaborative airway management is vital in preventing catastrophic airway obstruction in atypical forms of epiglottitis.
Assuntos
Queimaduras por Inalação/complicações , Epiglotite/etiologia , Vapor/efeitos adversos , Humanos , Lactente , MasculinoRESUMO
INTRODUCTION: Recent adult reports have demonstrated sub-optimal performance of basic cardiopulmonary resuscitation (CPR) skills in advanced training scenarios and real life arrest situations. We studied the adequacy of chest compressions performed by advanced trained pediatric providers in code scenarios. METHODS: We designed a prospective observational study of pediatric providers performing external closed-chest compressions on a child mannequin that is designed to assess adequacy based on depth and rate of chest compressions. The study was conducted from 2008 to 2009 in which 42 subjects were screened and enrolled for participation. Each subject underwent a basic life support scenario that included two minutes of uninterrupted external closed-chest compressions that were assessed for adequacy based on depth and rate. RESULTS: For 42 subjects, 168 total 30-s time segments were available for analysis. Chest compressions were performed at a median rate of 110 (interquartile range (IQR) of 75-145) compressions per minute (cpm). No significant decay in rate of chest compressions was noted over the two-minute evaluation. Chest compression depth was adequate in 9.4% of total delivered chest compressions. No statistical significance was found on the job exposure to CPR and delivery of effective chest compressions. CONCLUSION: Advanced training of pediatric providers does not ensure adequate delivery of chest compressions. Rate standards and adequate depth of chest compressions are infrequently achieved and both may need more emphasis in CPR training and attention during resuscitations.