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Postresuscitation Care in Pediatrics Patients

Eduardo J. Schnitzler, MD; Pablo G. Minces, MD;
Pablo Eulmesekian, MD

Unidad de Cuidados Intensivos Pediátricos, Hospital Italiano de Bs.As.,
Buenos Aires, Argentina

INTRODUCTION
   When spontaneous circulation is restored after a cardiopulmonary arrest (CPA) these are the goals of treatment:

Avoid CPA recurrence
Restore perfusion and oxygenation
Evaluate and monitor neurologic functions
Support dysfunctioning organs
Resolve the situation that promoted CPA

   Appropriate registration of the circumstances leading to the event is an important aspect: place, preceding clinical situation, related pathology, type of arrest (respiratory or cardiopulmonary), cardiac rhythm, times between CPA and cardiopulmonary resuscitation (CPR) and treatment maneuvers.

   Pediatric Utstein style gives a uniform way of registration that allows result analysis.

AVOID CPA RECURRENCE
   Restoration of spontaneous circulation means palpable pulses for at least 20 minutes. Potential causes of CPA recurrence could be: hypoxemia, respiratory failure, arrhythmias, cardiogenic, hypovolemic or distributive shock, cardiac tamponade, hypothermia, electrolyte disturbances or toxins that promote arrhythmias and hemodynamic problems.

   The most frequent causes of CPA in the pre-hospital setting are: near drowning, severe trauma, respiratory failure, sudden death infant syndrome, sepsis and arrhythmias. The primary goal is to support ventilation and oxygenation until spontaneous breathing returns. The airway should be open with adequate maneuvers, keeping in mind the potential for an unstable spine post trauma. Endotracheal intubation in this setting is controversial, specifically if the performer is not adequately trained. A prospective trial comparing intubation vs. bagging by paramedics in pre-hospital setting showed no significant difference in results between the two modes.

   Ventilation and oxygenation should be continuously monitored and any air leak problem such as pneumothorax should be quickly diagnosed. Pre-hospital treatment team should be trained to drain any tension pneumothorax. Normal ventilation values and O2 saturation >90% by pulse oximetry are recommended. Evaluation of circulatory status is done by palpating central and peripheral pulses and watching heart rate and cardiac rhythm in the monitor. Non invasive blood pressure should be measured with automatic devices. If the patient who received advanced CPA requires an urgent vascular access to infuse drugs, the most frequently used one in children younger than 5 years old is via an intra-osseous needle. This access should be well secured for transport. If heart rate is less than 60 bpm and perfusion is poor CPA should be started. If the cause that promoted CPA is hypovolemic shock fluid treatment should be considered during transport. Epinephrine infusion advantages for children with restored circulation after asystole or pulseless electric activity should be weighted against the technical disadvantages related to inadequate dose delivery and poor monitoring systems. Patients who suffered ventricular fibrillation should be monitored closely for a possible recurrence and a defibrillator device should be available.

   Regarding temperature control it is recommended to avoid hypothermia by keeping the patient dry in a normothermic environment. Blood glucose should be checked in infants and some other clinical situations by bedside reactive strips. Some toxic substances such as cocaine, tricyclic antidepressants, calcium blockers, beta blockers or opioids can be associated with CPA and require specific initial management.

   An important aspect related to pre-hospital attention is triage. It should be quick and also to an appropriate medical center that will meet the patient's potential medical or surgical needs. A safe transport requires nurses and physicians properly trained in pediatric emergencies, availability of pulse oximetry, EKG monitor and different pediatric size equipment.

IN HOSPITAL CARE
   Multi organ failure secondary to hypoxic ischemic insult requires partial or complete support of each organ function. Strategies to keep systemic perfusion and oxygenation adequate are the rule. Maintaining and protecting neurologic function is essential for a good outcome. Post resuscitation care means evaluation and support of A (airway), B (breathing), C (circulation) and D (disabilities or cerebral resuscitation).

   A Endotracheal intubation is required for a secure airway. Endotracheal tube patency and position should be periodically checked. Thoracic movement should be assessed and all four thoracic quadrants and axilla should be auscultated for air entry. Pulmonary compliance changes should be diagnosed and frequent endotracheal tube suctioning should be performed. Any accidental extubation, endotracheal tube blocking or displacement should be quickly diagnosed.

   B Any children post CPA should initially receive 100%O2. After stabilization FIO2 can be weaned. Children with respiratory failure, hemodynamic instability or decreased level of consciousness should remain mechanically ventilated. Initial ventilator setting depends on age and status of the patient. Invasive blood pressure, pulse oximetry, pH and PCO2 should be monitored. Mechanical ventilation goals are O2 saturation >88% with FIO2<60% and pH>7,35. Immediately after CPA hyper or hypoventilation should be avoided. Plateau pressures should be ideally <30 cmH2O. Different ventilation strategies include: PEEP, prone positioning and increased inspiratory time. In children with increased resistance in the airways autoPEEP should be measured and extrinsic PEEP adjusted to keep plateau pressure <30cmH2O. It may also be necessary to increase expiratory time.

   C After CPA some cardiovascular dysfunction exists and there are some conditions that promote it further: persistence of clinical situations that provoked the CPA (hypovolemia, sepsis, heart failure); cardiogenic shock secondary to hypoxic-ischemic myocardial insult; primary electrolyte disturbances or secondary to CPA (metabolic acidosis, hyperkalemia, hypokalemia, hypocalcemia); arrhythmias; cardiopulmonary interactions (PEEP, high airway pressures) and cardiac tamponade.

   Cardiovascular evaluation after CPA includes: clinical observation (central and peripheral pulses, capillary refill, heart rate, level of consciousness, diuresis) and monitoring (invasive blood pressure, central and peripheral temperature, EKG, pulse oximetry and central venous pressure). Acid basis status, ionized calcium, glucose, electrolytes and lactate should be measured intermittently. Echocardiogram allows evaluation of cardiac function and adjustment of inotropic and vasodilator drugs.

   The goal of treatment is to achieve adequate oxygen delivery by optimizing hemoglobin levels (>10gr/l), O2 saturation (>90%) and cardiac output. Temperature control and inhibition of muscular activity are helpful in decreasing O2 consumption.

   The most common hemodynamic pattern post CPA is a low cardiac output state with increased systemic vascular resistance. The inotropic drugs most frequently used are dopamine and epinephrine. Some patients also require vasodilator drugs such as sodium nitroprusside or nitroglycerine or inotropic/vasodilator drugs such as amrinone or milrinone. Recently, there has been increasing interest in vasopressin via continuous infusion for resuscitation in decreased systemic vascular resistance shock states. This drug potentially improves blood flow to vital organs so a better neurologic outcome could be obtained.

   Bradycardic disrhythmias may require epinephrine or transient pacing and tachycardic dysrhythmias may require cardioversion, adenosine, lidocaine or amiodarone.

   When resuscitation is successful lactic acidosis is cleared slowly and spontaneously. Bicarbonate infusions worsen patient status, mainly if ventilation and circulation are not optimal. Other electrolyte disturbances like hypokalemia, hyperkalemia or hypocalcemia should be detected and treated. Severe hypothermia should be treated with internal rewarming or extracorporeal circulation.

   D Neurologic damage should be prevented, evaluated and treated. Neurologic prevention depends on quick and effective CPR. CPA in children is mostly secondary to asystole that is secondary to hypoxia. Near drowning research has demonstrated a strong correlation between neurologic outcome and time of CPR initiation. Hypothermia initiated prior to circulatory arrest has a protective neurologic effect. Currently, moderate generalized hypothermia and localized hypothermia for the brain are being studied as neuroprotective measures. The damage produced by released activated excitatory neurotransmitters cannot be controlled with managing intracranial pressure and/or cerebral perfusion pressure.

   Known risk factors that increase secondary cerebral injury are: hyperthermia, hyperglycemia and hypotension. Hyperventilation is not recommended because it may aggravate vasoconstriction and promote ischemic injury.

   Neurologic evaluation should be performed once cardiopulmonary stability is achieved. Glasgow Coma Score, pupillary response and brain stem reflexes (oculo-vestibular, oculo-cephalic, cough and apnea test) are used to assess brain function. Children with no improvement in level of consciousness after 72 hours are more likely to have a poor neurologic outcome.

   E Mutiorgan dysfunction. The hypoxic-ischemic insult during CPA may affect different organs. Multiorgan dysfunction syndrome may include respiratory failure (acute respiratory distress syndrome), renal failure (acute tubular necrosis), hepatic failure and coagulation disturbances.

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
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