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2.
Pediatrics ; 145(1)2020 01.
Article in English | MEDLINE | ID: mdl-31727859

ABSTRACT

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.


Subject(s)
Advanced Cardiac Life Support , Airway Management/methods , American Heart Association , Heart Arrest/therapy , Child , Extracorporeal Membrane Oxygenation/methods , Humans , Hypothermia, Induced/methods , Out-of-Hospital Cardiac Arrest/therapy , United States
3.
Pediatrics ; 145(1)2020 01.
Article in English | MEDLINE | ID: mdl-31727861

ABSTRACT

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.


Subject(s)
American Heart Association , Cardiopulmonary Resuscitation , Emergency Medical Dispatcher , Out-of-Hospital Cardiac Arrest/therapy , Cardiopulmonary Resuscitation/mortality , Child , Humans , Out-of-Hospital Cardiac Arrest/mortality , United States
4.
Circulation ; 140(24): e904-e914, 2019 12 10.
Article in English | MEDLINE | ID: mdl-31722551

ABSTRACT

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.


Subject(s)
Airway Management/standards , Cardiopulmonary Resuscitation/standards , Emergency Medical Services/standards , Hypothermia, Induced/standards , Out-of-Hospital Cardiac Arrest/therapy , American Heart Association , Emergency Service, Hospital/standards , Humans , United States
5.
Circulation ; 140(24): e915-e921, 2019 12 10.
Article in English | MEDLINE | ID: mdl-31722546

ABSTRACT

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.


Subject(s)
Cardiopulmonary Resuscitation/standards , Emergency Medical Services/standards , Guidelines as Topic , Out-of-Hospital Cardiac Arrest/therapy , American Heart Association , Emergency Service, Hospital , Humans , United States
6.
Crit Care Nurs Clin North Am ; 31(3): 437-452, 2019 Sep.
Article in English | MEDLINE | ID: mdl-31351560

ABSTRACT

Cardiac surgical patients risk arrest from tamponade, profound bleeding, and hypovolemia, typically occurring within hours of intensive care admission and associated with diminished response to cardiopulmonary resuscitation (CPR). The Society of Thoracic Surgeons' evidence-based Expert Consensus Statement establishes a new standard for postsurgery arrest management, prioritizing defibrillation or pacing before CPR, restricting epinephrine use, and calling for prompt resternotomy if initial efforts fail. The protocol is summarized in a simple algorithm replacing advanced cardiac life support. This US cardiac surgical resuscitation standard is aligned with worldwide guidelines. Important information for protocol adoption and training is provided.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Electric Countershock/methods , Guidelines as Topic , Heart Arrest/therapy , Cardiopulmonary Resuscitation/adverse effects , Critical Care , Humans
7.
Innovations (Phila) ; 10(5): 296-303, 2015.
Article in English | MEDLINE | ID: mdl-26575376

ABSTRACT

Retained blood occurs when drainage systems fail to adequately evacuate blood during recovery from cardiothoracic surgery. As a result, a spectrum of mechanical and inflammatory complications can ensue in the acute, subacute, and chronic setting. The objectives of this review were to define the clinical syndrome associated with retained blood over the spectrum of recovery and to review existing literature regarding how this may lead to complications and contributes to poor outcomes. To better understand and prevent this constellation of clinical complications, a literature review was conducted, which led us to create a new label that better defines the clinical entity we have titled retained blood syndrome. Analysis of published reports revealed that 13.8% to 22.7% of cardiac surgical patients develop one or more components of retained blood syndrome. This can present in the acute, subacute, or chronic setting, with different pathophysiologic mechanisms active at different times. The development of retained blood syndrome has been linked to other clinical outcomes, including the development of postoperative atrial fibrillation and infection and the need for hospital readmission. Grouping multiple objectively measurable and potentially preventable postoperative complications that share a common etiology of retained blood over the continuum of recovery demonstrates a high prevalence of retained blood syndrome. This suggests the need to develop, implement, and test clinical strategies to enhance surgical drainage and reduce postoperative complications in patients undergoing cardiothoracic surgery.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Postoperative Complications/etiology , Blood Loss, Surgical , Drainage/adverse effects , Humans , Postoperative Complications/prevention & control , Syndrome , Treatment Failure
9.
Semin Cardiothorac Vasc Anesth ; 19(2): 87-94, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25975593

ABSTRACT

Perioperative arrest occurs in thousands of cardiac surgical patients annually, yet standard resuscitation methods are ineffective or potentially harmful. These "high risk, low volume" events typically occur in well-monitored patients in the highly specialized environment of the operating room or intensive care unit, with a short list of likely causes of arrest, making a protocolized approach to management feasible and desirable. An evidence-based guideline for resuscitation specific to the cardiac surgical patient was first published by Dunning et al in 2009 and adopted by the European Resuscitation Council the following year. It emphasizes important deviations from advanced cardiac life support, including immediate defibrillation or pacing of arrhythmias before external compressions, if feasible within 1 minute, and avoidance of epinephrine due to potential rebound hypertension. In standard fashion, the rapid exclusion of reversible causes of arrest is followed by chest reopening within 5 minutes. This approach is now standard of care in most European countries and is under review for use in the United States by the Society of Thoracic Surgeons. The anesthesiologist, as either team leader or participant, plays a critical role in optimally managing arrests after cardiac surgery. Their familiarity with this new standard is essential to optimal patient outcomes.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Heart Arrest/therapy , Resuscitation/methods , Anesthesiology/methods , Electric Countershock/methods , Evidence-Based Medicine/methods , Heart Arrest/etiology , Humans , Intensive Care Units , Operating Rooms , Practice Guidelines as Topic , Resuscitation/adverse effects , Time Factors
10.
Crit Care Nurse ; 35(2): 30-7; quiz 38, 2015 Apr.
Article in English | MEDLINE | ID: mdl-25834006

ABSTRACT

Of the 250 000 patients who undergo major cardiac operations in the United States annually, 0.7% to 2.9% will experience a postoperative cardiac arrest. Although Advanced Cardiac Life Support (ACLS) is the standard approach to management of cardiac arrest in the United States, it has significant limitations in these patients. The European Resuscitation Council (ERC) has endorsed a new guideline specific to resuscitation after cardiac surgery that advises important, evidence-based deviations from ACLS and is under consideration in the United States. The ACLS and ERC recommendations for resuscitation of these patients are contrasted on the basis of the essential components of care. Key to this approach is the rapid elimination of reversible causes of arrest, followed by either defibrillation or pacing (as appropriate) before external cardiac compressions that can damage the sternotomy, cautious use of epinephrine owing to potential rebound hypertension, and prompt resternotomy (within 5 minutes) to promote optimal cerebral perfusion with internal massage, if prior interventions are unsuccessful. These techniques are relatively simple, reproducible, and easily mastered in Cardiac Surgical Unit-Advanced Life Support courses. Resuscitation of patients after heart surgery presents a unique opportunity to achieve high survival rates with key modifications to ACLS that warrant adoption in the United States.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Cardiopulmonary Resuscitation/methods , Cardiopulmonary Resuscitation/standards , Heart Arrest/therapy , Hospital Mortality , Cardiac Surgical Procedures/methods , Cause of Death , Electric Countershock/methods , Electric Countershock/standards , Female , Follow-Up Studies , Heart Arrest/etiology , Heart Arrest/mortality , Humans , Male , Postoperative Complications/diagnosis , Postoperative Complications/mortality , Postoperative Complications/therapy , Risk Assessment , Survival Analysis , United States
16.
Ann Thorac Surg ; 85(1): 195-8, 2008 Jan.
Article in English | MEDLINE | ID: mdl-18154809

ABSTRACT

BACKGROUND: The use of a stentless aortic bioprosthesis offers the advantages of a larger effective valve orifice size, reduced transvalvular gradients, and improved hemodynamics versus stented valves. We hypothesized that these features would make the Toronto stentless porcine valve a preferred choice for patients with congenital abnormalities of the right ventricular outflow tract. METHODS: We retrospectively reviewed medical records of 21 patients with tetralogy of Fallot who subsequently underwent right ventricular outflow tract reconstruction during a 6-year period. RESULTS: The majority of patients received a 29-mm valve (n = 13), 5 received a 27-mm valve, with 1 each additional implant of a 19-, 22-, and 23-mm prosthesis. The mean age and weight were 24.5 years (range, 7 to 54 years) and 55.6 kg (range, 13.9 to 98.0 kg), respectively. Preoperatively, all patients had severe pulmonary insufficiency, mixed with mild to moderate stenosis in 2. The duration of postoperative echocardiographic follow-up ranged from 10 to 70 months (mean, 37.7 months). At the time of most recent follow-up, pulmonary insufficiency was graded as zero to trace in 47.4% (9 of 19 patients), mild in 42.1% (8 of 19 patients), and moderate in 10.5%, with 6 patients (31.6%) having concomitant pulmonary stenosis. The most recent mean and peak transvalvular gradients averaged 17.4 mm Hg (range, 11 to 24 mm Hg) and 26 mm Hg (range, 13 to 42 mm Hg), respectively. There have been no valve-related complications or explants, with one late death as a result of a noncardiac cause. CONCLUSIONS: The stentless porcine valve is well suited for valve replacement in children, adolescents, and adults with congenital abnormalities of the right ventricular outflow tract, regardless of patient or valve size, particularly when significant downstream hemodynamic abnormalities exist.


Subject(s)
Bioprosthesis , Heart Valve Prosthesis Implantation/methods , Heart Valve Prosthesis , Pulmonary Valve/surgery , Ventricular Outflow Obstruction/surgery , Adolescent , Adult , Animals , Child , Female , Follow-Up Studies , Humans , Male , Middle Aged , Probability , Prosthesis Design , Plastic Surgery Procedures/methods , Retrospective Studies , Risk Assessment , Stents , Swine , Tetralogy of Fallot/complications , Tetralogy of Fallot/diagnosis , Tetralogy of Fallot/surgery , Treatment Outcome , Ventricular Outflow Obstruction/diagnosis , Ventricular Outflow Obstruction/etiology
17.
Am J Crit Care ; 13(4): 292-301; discussion 302; quiz 303-4, 2004 Jul.
Article in English | MEDLINE | ID: mdl-15293581

ABSTRACT

BACKGROUND: Pain during chest tube removal can be moderately to severely intense and distressful to patients. Little evidence-based research has guided clinicians in attempts to alleviate such pain. OBJECTIVE: To test pharmacological and nonpharmacological interventions to alleviate pain during chest tube removal in cardiac surgery patients. METHODS: Four interventions were tested in 74 patients in a randomized, double-blind study: (1) 4 mg intravenous morphine and procedural information; (2) 30 mg intravenous ketorolac and procedural information; (3) 4 mg intravenous morphine plus procedural and sensory information; and (4) 30 mg intravenous ketorolac plus procedural and sensory information. Analgesics were administered to correspond to peak effect, and scripted information was provided. Pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and 20 minutes later Pain quality was measured immediately after chest tube removal. Level of sedation was measured before and 20 minutes after chest tube removal. Repeated-measures analyses of variance were used to test differences among groups over time. RESULTS: Pain intensity, pain distress, and sedation levels did not differ significantly among groups. However, procedural pain intensity (mean 3.26, SD 3.00) and pain distress (mean 2.98, SD 3.18) scores for all were low. Patients remained alert, regardless of which analgesic was administered. CONCLUSIONS: If used correctly, either an opioid (morphine) or a nonsteroidal anti-inflammatory (ketorolac) can substantially reduce pain during chest tube removal without causing adverse sedative effects. Thus, clinicians may choose among several safe and effective analgesic interventions during chest tube removal.


Subject(s)
Analgesics, Opioid/administration & dosage , Anti-Inflammatory Agents, Non-Steroidal/administration & dosage , Chest Tubes/adverse effects , Device Removal/adverse effects , Pain/prevention & control , Aged , Analgesics, Opioid/therapeutic use , Analysis of Variance , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Double-Blind Method , Drug Administration Schedule , Female , Humans , Ketorolac/administration & dosage , Ketorolac/therapeutic use , Male , Morphine/administration & dosage , Morphine/therapeutic use , Pain/etiology , Pain Measurement , Postoperative Care/methods , Time Factors
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