...and home again

Apologies for not writing last night after a busy day of listening to new information about resuscitation, and meeting with old friends and new acquaintances. Lots of walking around the San Francisco Embarcadero area, and the need to go to sleep early so I could rise at 4am to catch my plane home, lead me to  postpone the post I promised on the soon-to-be released new approaches to CPR in children.

Have you ever wondered how it is that health care providers KNOW the right way to bring someone back to life after they have suffered stoppage of the heart (known as cardiac arrest)? Well, for many years it has been basically guess-work, supplemented by gathering data on people who have had this happen to them, as well as some animal studies. For CPR in children, most of us have had to extrapolate from studies in adult populations or animals (at some later time we can discuss the issues of using animals to study human disease). Only recently have researchers been inclined to or been able to really study how children respond to performance of CPR. There are many reasons for this, but the main reason is that (fortunately) children experience cardiac arrest much less frequently than adults.

It is estimated that each year in the US, approximately 300,000 adults may suffer a cardiac arrest, whereas only about 5000 children arrest outside of a hospital. Although a relatively small number, when it happens it is often deadly (about one third will survive). When you divide the total number of children who arrest by the number of places where they may arrest, or the locations in which emergency medical personnel may be called upon to resuscitate them, you can understand that most medical personnel have very limited experience and exposure to children who are so sick that they sustain a cardiac arrest. That is one reason why you want sick children to be cared for in places where they care for a lot of sick children--another topic we can deal with at a later date.

Well, anyway, in the last couple of decades, pediatricians with special expertise in caring for very sick children (pediatric intensivists, pediatric cardiologists, pediatric emergency medicine specialists), have been working diligently with the American Heart Association (AHA) to develop resuscitation guidelines just for kids. Every 5 years or so, they review available research and publish guidelines for how to best resuscitate a child. The latest guidelines will be released on October 18 at www.circ.ahajournals.org along with new guidelines for resusciation of adults.

At Carilion Clinic Children's Hospital, our Pediatric Advanced Life Support program teaches health care providers to resuscitate according to the latest guidelines. We will be updating our educational programs once the AHA releases its recommendations, and revises the training programs. So I will be watching along with you to see the new guidelines when they are released, and we can discuss them at that time. Stay tuned...

Comments

Thank you for your comments!
As a pediatric intensivist here in the Carilion system, I have been working with the adult units on the use of therapeutic hypothermia and have been trying to determine to which of the pediatric post arrest patients we should offer this modality. In my reveiw of the literature, I find no published evidence that cooling will benefit the typical post arrest pediatric patient but did find information about two ongoing national multicenter trials looking at this. Those studies have not been ongoing very long and do not propose to have final data before 2015. Did the lectures you attended make any comment about therapeutic hypothermia? What were the findings?

Virginia,
Thanks for asking. This is a very important question. There was major discussion about the topic of therapeutic hypothermia presented at the meeting. You have hit the nail on the head, when you indicate that there is NO EVIDENCE IN PEDIATRICS EXCEPT IN NEONATES, that therapeutic hypothermia is beneficial, and it might be harmful, so we were cautioned to NOT jump in and just do it in all patients who have been resucitated from a cardiac arrest. However, there is GOOD DATA to support prevention of HYPERTHERMIA (higher than normal body temperature) as outcome worsens significantly for every degree in the celcius system over 37. It is believed that fevers generate worse outcomes through a variety of mechanisms, including causing an increase in cerebral metabolism that then requires more blood flow and might cause the pressure in the brain to rise, an increase in the generation of free radicals, that can cause cellular damage, more inflammation that can also cause brain swelling, andan increase in the rate at which brain cells die. So, the bottom line is that until we have better data from the studies you mentioned that are now underway, we should do everything we can to keep the patient's temperature within the normal range for the first 48 hours after the cardiac arrest and resuscitation occured.

The lecture I attended on this topic was presented by Dr. Erica Fink, a pediatric intensivist who works at the Safar center for resuscitation research in Pittsburgh http://www.chp.edu/CHP/Fink,+Ericka+L.,+MD
It is associated with Pittsburgh Children's Hospital.

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