BCC4: Lockie on Resuscitating the Lungs
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Fran Lockie, provides a useful update on paediatric drowning sequalae and outcomes. This talk was recorded at Bedside Critical Care Conference. For audio for this and similar talks, please visit www.intensivecarenetwork.com The next BCC will be held in Cairns, 29th September - 3rd of October: http://bedsidecriticalcare.com/
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BCC4: Lockie on Resuscitating the Lungs
- 1. Paediatrics: Immersion Update Dr Fran Lockie MedSTAR Paediatric Emergency, WCH Bedside Critical Care, September2013
- 2. Sydney Based Health practitioner Passion for female weight loss ‘www.Hotfatchicks.com’
- 3. Sydney Based Health practitioner Passion for female weight loss ‘www.Hotfatchicks.com’
- 4. Scope • Case • Definitions/Guidelines • Epidemiology • Outcome • Management
- 7. Case Study • Winter in the Blue Mountains: • 11:30am: mother and two children (2 and 4 yrs) lay down for a nap • 11:50am: Neighbour accompanies 4-yr old to knock on the door and wake mother; found outside on street with wet trousers. Says brother under water. • Approx. 12:10pm: Mother spots 2-yr old under water in creek by the road, several minutes walk from the house • Mother retrieves 2-year old from cold creek: Pale with circumoral cyanosis, apnoeic, pulseless and widely dilated pupils. • Mother commences CPR at scene; ambulance called by neighbour at 12:13pm
- 8. • Paramedics arrive and assist CPR. GCS = 3. ?weak pulse; ?child moves one arm. • Adult retrieval team:no pulse, pupils fixed and dilated and no signs of life – CPR continued – Intubated – IO sited – 3 x Adrenaline • 1:18pm: Arrived ED – Spontaneous agonal respirations – Femoral pulse palpable – Closed chest compressions ceased
- 9. • Shut-down ++. Rectal temp <26.7 C • Arterial gas: pH 7.06, paO2 219, PaCO2 31, HCO3 8.8, BE - 21 • GCS 3; pupils 4mm F&D • Rewarmed: humidified gas, overhead heater, gel pads, bair-hugger, warm saline solution bladder irrigation and bags of warm normal saline solution to groins and axillae • Measured temperature increased >26.7 C after 30 min • Active rewarming (except warm humidified insp gases) ceased when temp 30 C
- 10. • Moves fingers prior to transfer to PICU • Temperature rose spontaneously to 36.7 C 6-hrs after admission. • 48-hrs Hi-PEEP low volume Ventilation for pulmonary oedema / ALI • Haemoglobin fell from 12.8 in ED to 9.8 g/dL 12-hrs later • Urine coloured red on Day 1. No RRT. • Eyes open Day 4 • Generalised weakness; slow to wean from ventilator • 2-weeks later: Self-ventilating, weight-bearing and some verbalisation • 23 days post immersion: Discharged home walking and talking • 6-months later: Mild speech delay
- 11. • ‘..respiratory impairment from submersion / immersion in liquid..’ • Outcomes defined • 388 000 deaths / year
- 12. • ‘..respiratory impairment from submersion / immersion in liquid..’ • Outcomes defined National Drowning Report, RLSA, 2011
- 13. 0 10 20 30 40 50 60 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 PICU Admissions, Drowning, 2000- 2011 ANZPIC Registry
- 14. • Need more research: OHCA vs drowning • In water EAR if unresponsive 10-15 breaths • Early intubation with cuffed ETT • ECG, ET CO2 to confirm arrest. Keep going! • < 30 degrees: only 3 x defib attempts, no drugs until temp > 30 • Rewarm to 32-34 degrees. Avoid temp > 37
- 15. Patterns of Drowning in Australia 1992- 1997 Mackie MJA 1999
- 16. Mackie MJA 1999 Bathtub Drownings Age (years)
- 17. Mackie MJA 1999 Bathtub Drownings Age (years)
- 18. Ocean/estuary (n=346) Private pool (n=265) Lakes/waterholes/lagoons (n=265) Surfing beach (n=162) Fishing (n=90) Scuba (n=56) Age (years) Location
- 19. • 12.1% Overall survival to hospital discharge; 4% intact neurological survival • Submersion injuries included in 30 of 41 studies and examined exclusively in 2 studies • 22.7% (63 of 227) survived to hospital discharge • 6% (7 of 117) had no neurological sequelae at discharge Donaghue et al Ann Emerg Med. 2005
- 20. Resuscitation 2013 • 66716: 1300 children, 61000 adults • 1736 adults and 68 kids post drowning • One month survival, neurologically favourable one-month survival • Better survival but no difference in good neuro outcomes
- 22. Christensen et al Peds, 1997 92% 6%
- 23. Christensen et al Peds, 1997 ‘Even fixed and dilated pupils, low GCS, need for CPR in ED have proven unreliable in individual cases’ ‘Composite score based on ED physical exam (apnoea, coma) + need for CPR + lowest pH …..best available ……but even this 93% accurate in their hands’
- 24. Poor Prognostic Factors Include • Submersion time > 5 to 10 min • Fixed and dilated pupils (NB: Effect of severe hypothermia) • No or delayed bystander CPR • Time to first gasp > 40 min • Need for CPR >25 min • Need for CPR in ED • Initial pH < 7.00 • Persistence of coma in ED and ICU 24 hrs after immersion • Abnormal CT within 36 hrs of submersion Modell JH, Chest 1976 Suominen P, Resuscitation 1997 Quan L, Pediatrics 1990 Peterson B, Pediatrics 1977 Bratton SL, Arch Pediatr Adolesc Med 1994
- 25. ICU Prediction of Outcome ? • PE: GCS ≥ 6 or purposeful movement + intact brainstem reflexes v likely good outcome • SEPS: absent SEPS 100% predictive of poor outcome • Imaging: Early (8h) abnormal CT strongly predictive for bad outcome; normal CT uninformative MRI more specific but need 3-4 days to avoid inappropriate optimism
- 26. Is Cold Immersion Protective? • Well documented and supported by animal studies1,2 • Hypothermia reduces oxygen consumption – approximately 7% per degree Celcius drop in body temperature • Heat loss can be rapid – Large SA to volume ratio. Cold fluid in lungs:excellent heat exchangers • Unfortunately: – Diving refleximmersion induced apnoea and layngospasm – Clothes 1. Kvittingen TT, Naess A, BMJ 1963 2. Orlowski JP, JAMA 1988
- 27. Suominen Resuscitation 1997, 2002 Impact of age, submersion time and water temperature on outcome in near drowning? • Finland regional survey – most drownings occur in cold water • 61 admissions to ICU Helsinki over 12 y: water temp, rectal temp, and estimated submersion time • Median water temp 17C (range 0-33)…lower in survivors but much cross over • 80% admission temp < 35C (no diff S & NS) • Est submersion time only independent predictor of survival (5’ V 16’) but no clear cut off could be defined
- 28. 04/20/99 Presentation of near drowning 2 types of presentation • 1. Awake alert after nil or brief Respiratory Arrest – should do well with good care – may get serious lung pathology (ALI / ARDS / pneumonia) – admit and observe CXR, ABG – good prognosis
- 29. 04/20/99 Presentation of near drowning 2 types of presentation • 1. Awake alert after nil or brief Respiratory Arrest – should do well with good care – may get serious lung pathology (ALI / ARDS / pneumonia) – admit and observe CXR, ABG – good prognosis
- 30. 04/20/99 Presentation of near drowning • 2. Post Cardiac arrest – Need resuscitation, stabilisation and ICU
- 32. Pulmonary oedema, pneumonia (25- 50%), ARDS < 10% Neurogenic Altered capillary permeability Forced inspiration against a closed glottis Surfactant dysfunction
- 33. Fluid shifts Aspiration of debris pneumonitis Infection (rare) Surfactant depletion
- 34. Assessment and Management of Immersion injury • Primary survey ABC’s • Empty the stomach with a gastric tube • Early Intubation • PEEP, minimise VILI
- 35. Assessment and Management: Circulation • Hypoxic, cold myocardium Prone to arrhythmias and arrest Likely to need inotropic support Active rewarming essential • Peripheral vasoconstriction May need vasodilators once blood pressure restored • Cold diuresis
- 36. Level Temp range Techniques Mild 35oC - 32oC Passive external re-warming -overhead lights -remove wet clothing -warm blankets Moderate 32oC – 30oC Active external re-warming -warmed IV fluids (microwave or fluid warmer) -warmed humidified gas for ventilation (humidifier) -warm saline bags to inguinal and neck areas (microwave) Warning: passive external re-warming may contribute to a drop in core temperature especially if applied to limbs Severe 30oC – 25oC Active internal re-warming plus active external -bladder irrigation with warmed saline -peritoneal irrigation with warmed saline (pigtail catheter, fluid warmer), -pleural (right side) with warmed saline (pigtail catheter, fluid warmer) -discuss bypass for those in cardiac arrest with intensivist Techniques of Warming
- 37. Resuscitation 2002 Artif Organs, Vol. 34, No. 11, 2010 Suominen Acta Anaesthesiol Scand 2010
- 38. Assessment and Management: Other issues • No evidence – Anti-convulsants – Antibiotics (Wood, ADC, 2010) – Steroids (Foex, ADC, 2002) • Continuous EEG monitoring • Hyponatraemia and electrolyte abnormalities • Coagulopathy (with hypothermia) and later thrombocytosis • Haemolysis or rhabdomyolysis • Therapeutic Hypotherrmia “Cooling” ?
- 39. Pediatr Emer Care 2010
- 40. Pediatr Emer Care 2010
- 41. Lancet Neurol 2013 • 48-72 hrs therapeutic hypothermia with slow re-warming • 77 patients • 39 cooled, 38 normothermia • No differences in adverse events • GOS almost identical • Terminated early due to futility
- 43. Paed OHCA 32-34C for 48h then 36-37.5C for 3d 36-37.5C for 5d Within 6h of ROSC * Drowning victims with core temp <32C on arrival specifically excluded
- 44. Kids Alive - Do the Five Water Safety Programme 1. Fence the pool. 2. Shut the gate. 3. Teach your kids to swim-it’s great. 4. Supervise 5. Learn how to Resuscitate. www.kidsalive.com.au
- 47. Summary • Individualise care • Don’t make assumptions – Opportunities to withdraw won’t go away • Kids are resilient (with unreliable parents!) • Re-warm • High quality neuro-ICU • Don’t forget the family and Resus team
Notas do Editor
- More research comparing OHCA due to drowning with primary cardiac OHCA neededIn-water EAR if victim unresponsive, 10-15 breaths in 1 minute then decide based on est time to shore< 5 mins continue EAR while towing> 5 mins give 1 more minute EAR then head off uninterruptedEarly intubation with cuffed ETT, not LMA or GuedelUse ECG, ET CO2 or echo to confirm arrest. Be wary to discontinue resus efforts in the fieldCore temp < 30C : limit defib to x3 and withold drugs till core temp > 30CRecommends rewarming hypothermic patient to 32-34C and avoid temps >37C during subsequent intensive care course
- Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity and no morbidity. Agreed terminology is essential to describe the problem and to allow effective comparisons of drowning trends. Thus, this definition of drowning adopted by the 2002 World Congress on Drowning should be widely used.near drowning” “dry or wet drowning” “secondary drowning” “delayed onset respiratory distressIn 2004, an estimated 388 000 people died from drowning, making drowning a major public health problem worldwide. It should be borne in mind that there is a wide range of uncertainty around the estimate of global drowning deaths and that the global problem is much greater than these figures reveal due to a number of reasons. These include issues with the manner in which data are classified, meaning that these global numbers exclude drowning due to floods (cataclysms), boating and water transport mishaps. Non-fatal drowning statistics in many countries are not readily available or are unreliable. The vast majority (approximately 96%) of all drowning deaths occurred in low- and middle-income countries. The Western Pacific and South East Asia regions account for 60% of the mortality and DALYs. In general, children under 5 years of age have the highest drowning mortality rates worldwide.
- Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity and no morbidity. Agreed terminology is essential to describe the problem and to allow effective comparisons of drowning trends. Thus, this definition of drowning adopted by the 2002 World Congress on Drowning should be widely used.near drowning” “dry or wet drowning” “secondary drowning” “delayed onset respiratory distressIn 2004, an estimated 388 000 people died from drowning, making drowning a major public health problem worldwide. It should be borne in mind that there is a wide range of uncertainty around the estimate of global drowning deaths and that the global problem is much greater than these figures reveal due to a number of reasons. These include issues with the manner in which data are classified, meaning that these global numbers exclude drowning due to floods (cataclysms), boating and water transport mishaps. Non-fatal drowning statistics in many countries are not readily available or are unreliable. The vast majority (approximately 96%) of all drowning deaths occurred in low- and middle-income countries. The Western Pacific and South East Asia regions account for 60% of the mortality and DALYs. In general, children under 5 years of age have the highest drowning mortality rates worldwide.
- More research comparing OHCA due to drowning with primary cardiac OHCA neededIn-water EAR if victim unresponsive, 10-15 breaths in 1 minute then decide based on est time to shore< 5 mins continue EAR while towing> 5 mins give 1 more minute EAR then head off uninterruptedEarly intubation with cuffed ETT, not LMA or GuedelUse ECG, ET CO2 or echo to confirm arrest. Be wary to discontinue resus efforts in the fieldCore temp < 30C : limit defib to x3 and withold drugs till core temp > 30CRecommends rewarming hypothermic patient to 32-34C and avoid temps >37C during subsequent intensive care course
- ----- Meeting Notes (26/09/13 11:51) -----It takes 32 seconds for a child to die: I heard this on Ophah
- ----- Meeting Notes (26/09/13 11:51) -----It takes 32 seconds for a child to die: I heard this on Ophah
- Study objective: We systematically summarize pediatric out-of-hospital cardiac arrest epidemiologyand assess knowledge of effects of specific out-of-hospital interventions. Methods: We conducted a comprehensive review of published articles from 1966 to 2004, availablethrough MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EmBase, and the CochraneRegistry, describing outcomes of children younger than 18 years with an out-of-hospital cardiac arrest.Patient characteristics, process of care, and outcomes were compared using pediatric Utstein outcomereport guidelines. Effects of out-of-hospital care processes on survival outcomes were summarized. Results: Forty-one studies met inclusion criteria; 8 complied with Utstein reporting guidelines. Includedin the review were 5,363 patients: 12.1% survived to hospital discharge, and 4% survivedneurologically intact. Trauma patients (n=2,299) had greater overall survival (21.9%, 6.8% intact); aseparate examination of studies with more rigorous cardiac arrest definition showed poorer survival(1.1% overall, 0.3% neurologically intact). Submersion injury–associated arrests (n=442) had greateroverall survival (22.7%, 6% intact). Pooled data analysis of bystander cardiopulmonary resuscitationand witnessed arrest status showed increased likelihood of survival (relative risk 1.99, 95% confidenceinterval 1.54 to 2.57) for witnessed arrests. The effect of bystander cardiopulmonary resuscitation isdifficult to determine because of study heterogeneity. Conclusion: Outcomes from out-of-hospital pediatric cardiac arrest are generally poor. Variability mayexist in survival by patient subgroups, but differences are hard to accurately characterize. Conformitywith Utstein guidelines for reporting and research design is incomplete. Witnessed arrest statusremains associated with improved survival. The need for prospective controlled trials remains a high
- 41 Studies5000 OHCAStudy objective: We systematically summarize pediatric out-of-hospital cardiac arrest epidemiologyand assess knowledge of effects of specific out-of-hospital interventions. Methods: We conducted a comprehensive review of published articles from 1966 to 2004, availablethrough MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EmBase, and the CochraneRegistry, describing outcomes of children younger than 18 years with an out-of-hospital cardiac arrest.Patient characteristics, process of care, and outcomes were compared using pediatric Utstein outcomereport guidelines. Effects of out-of-hospital care processes on survival outcomes were summarized. Results: Forty-one studies met inclusion criteria; 8 complied with Utstein reporting guidelines. Includedin the review were 5,363 patients: 12.1% survived to hospital discharge, and 4% survivedneurologically intact. Trauma patients (n=2,299) had greater overall survival (21.9%, 6.8% intact); aseparate examination of studies with more rigorous cardiac arrest definition showed poorer survival(1.1% overall, 0.3% neurologically intact). Submersion injury–associated arrests (n=442) had greateroverall survival (22.7%, 6% intact). Pooled data analysis of bystander cardiopulmonary resuscitationand witnessed arrest status showed increased likelihood of survival (relative risk 1.99, 95% confidenceinterval 1.54 to 2.57) for witnessed arrests. The effect of bystander cardiopulmonary resuscitation isdifficult to determine because of study heterogeneity. Conclusion: Outcomes from out-of-hospital pediatric cardiac arrest are generally poor. Variability mayexist in survival by patient subgroups, but differences are hard to accurately characterize. Conformitywith Utstein guidelines for reporting and research design is incomplete. Witnessed arrest statusremains associated with improved survival. The need for prospective controlled trials remains a high priority The lack of uniformity of case definition continues to be aproblem in studies of pediatric cardiopulmonary arrest,although some improvement can be noted. We chose to excludearticles that did not report survival to hospital discharge as anoutcome based on the fact that it was the most widely reportedoutcome in studies eligible for this review and arguably a moremeaningful one in terms of long-term functional outcome thanother Utstein categories of return of spontaneous circulationand survival. The ideal outcome measure, that of the overallchange in neurocognitive function from the prearrest topostarrest periods, is not evaluable from the majority of thesestudies. Young and Seidel1 recommended that neurologicoutcomes be reported uniformly, when possible in theframework of a validated scoring system such as the PediatricCerebral Performance Category. This recommendationrepresents the most important clinical outcome for the arrestedchild and at the same time is one of the most difficult tostudy in a well-designed fashion in that it requires long-termfollow-up data that are challenging to collect, as well assubjective, which renders them difficult to accurately quantify insome cases. The most recent study in this review designated aseparate category of ‘‘Pediatric Cerebral Performance Categoryunchanged from baseline.’’44 Although the overall change inneurologic status is possibly the outcome that best reflects theeffectiveness of a patient’s resuscitation, the interpretation of anunchanged Pediatric Cerebral Performance Category is difficultif the initial Pediatric Cerebral Performance Category isabnormal. The designation of ‘‘intact neurologic survival’’ usedin this article should be inferred as being based on the bestinterpretation possible from the present literature,acknowledging the inconsistencies described above.Bystander CPR has been well documented in several adultstudies to have a favorable impact on outcome in the arrestedadult. In the first phase of the Ontario Prehospital AdvancedLife Support study, Stiell and colleagues found that 14.5% ofadults received bystander CPR and that bystander CPR wasan independent predictor of survival in arrested adults.50 Rates of bystander CPR were higher in children in this review,with an overall rate of 32%. Existing studies of pediatricCPR suggest that rates of bystander CPR in children areworse than in adults. As mentioned above, cases in whichbystander CPR is successful (ie, return of spontaneouscirculation is achieved before EMS arrival) are frequently notincluded in studies of pediatric arrests. Our review suggests thatbystander CPR remains an understudied intervention withsignificant potential to improve outcomes for arrested children.Children who have submersion injury (Tables 3c and 4b )demonstrated some important differences with respect toclinical features and outcomes. Overall survival to hospitaldischarge and intact neurologic survival was better than theoverall sample (22.7% versus 12.1% survival and 6.0% versus4.0% intact neurologic survival) for patients with submersioninjury. Debate has existed historically about the utility ofaggressive resuscitation of submersion victims with cardiac arrestor coma in the out-of-hospital phase. Some authors suggestthat certain patients need not undergo drastic efforts in lightof the extreme unlikelihood of meaningful survival.51-53 Orlowski54 found that the early institution of resuscitativeefforts had the greatest impact on survival for submersionvictims. Studies by Lavelle and Shaw55 in 1993 and Allmanet al56 in 1986 found that outcomes of submersion victims werepositively affected by emergency resuscitative efforts but failedto demonstrate any positive influence of aggressive cerebralresuscitation in the intensive care setting. The results of thepresent review suggest that the survivability of cardiac arrest maybe improved for patients who arrest as a result of submersion.Trauma patients represented a significant subset ofcardiopulmonary arrest patients in all studies from which theywere not excluded. Discrepancies in the results yielded by theinclusion of data from the National Pediatric Trauma Registryexemplify that case definition in studies of pediatriccardiopulmonary arrest lacks uniformity. The overall survivaland intact neurologic survival of trauma patients in this review,
- Background: Children have better outcomes after out-of-hospital cardiac arrest (OHCA) than adults. How-ever, little is known about the difference in outcomes between children and adults after OHCA due to drowning. Objectives: The aim of this study is to assess the outcome after OHCA due to drowning between children and adults. Our hypothesis is that outcomes after OHCA due to drowning would be in better among children (<18 years old) compared with adults (≥18 years old). Method: This prospective population-based, observational study included all emergency medical service-treated OHCA due to drowning in Osaka, Japan, between 1999 and 2010 (excluding 2004). Outcomes were evaluated between younger children (0–4 years old), older children (5–17 years old), and adults (≥18 years old). Major outcome measures were one-month survival and neurologically favorable one-month survival defined as cerebral performance category 1 or 2. Multivariate logistic regression analyses were used to account for potential confounders. Results: During the study period, 66,716 OHCAs were documented, and resuscitation was attempted for 62,048 patients (1300 children [2%] and 60,748 adults [98%]). Among these OHCAs, 1737 (3% of OHCAs) were due to drowning (36 younger children [2%], 32 older children [2%], and 1669 adults [96%]). The odds of one-month survival were significantly higher for younger children (28% [10/36]; adjusted odds ratio [AOR], 20.20 [95% confidence interval {CI} 7.45–54.78]) and older children (9% [3/32]; AOR, 4.47 [95% CI 1.04–19.27]) when compared with adults (2% [28/1669]). However, younger children (6% [2/36]; AOR, 5.23 [95% CI 0.52–51.73]) and older children (3% [1/32]; AOR, 2.53 [95% CI 0.19–34.07]) did not have a higher odds of neurologically favorable outcome than adult s (1% [11/1669]). Conclusion: In this large OHCA registry, children had better one-month survival rates after OHCA due to drowning compared with adults. Most survivors in all groups had unfavorable neurological outcomes. © ?2?0?1?3? ?E?l?s?e?v?i?e?r? ?I?r?e?l?a?n?d? ?L?t?d?.? ?A?l?l? ?r?i?g?h?t?s? ?r?e?s?e?r?v?e?d?.? ?
- CALIFORNIA Prehospital resuscitation, including early intubation,ventilation, vascular access, and administrationof advanced life support medications.2. Continued resuscitation and stabilization in theED.3. Full supportive care in the pediatric intensive careunit for a minimum of 48 hours.4. Consider withdrawal of support if no neurologicimprovement is detected after 48 hours. Ancillarytesting such as brainstem evoked responses, electroencephalography,and magnetic resonancespectroscopy may prove helpful to corroboratethe neurologic examination.5. Aggressive pursuit of potential new therapies forABSTRACT. Objective. Predictive efforts using individualfactors or scoring systems do not adequately identifyall intact survivors, and therefore all drowning victimsare aggressively resuscitated in most emergencydepartments. More reliable outcome prediction is neededto guide early treatment decisions.Methods. The charts of 274 near drowning patientsadmitted to Loma Linda University Children’s Hospitalwere retrospectively reviewed. Patient outcome was categorizedinto good (near normal function), and poor (vegetativeor dead) categories. Discriminant analysis wasused to identify combinations of variables most able topredict outcome and a clinical classification system wasconstructed. The acute care hospital costs for each groupwere compared.Results. Discriminant analysis classification achieved95% accuracy, predicting death in 6 intact survivors. Nocombination of variables could accurately separate allintact survivors from the vegetative and dead groups.The clinical classification method achieved 93% overallaccuracy, predicting death in 5 intact survivors. Of patientspredicted to have a poor outcome, 5 (6.3%) survivedintact. Children may experience an unpredictable, prolongedvegetative state followed by full recovery. Vegetativepatients are the most expensive to care for (consuming53% of total costs) while intact survivors are theleast expensive. The majority of costs were spent onpatients with poor outcome.Conclusions. Individual outcome cannot be reliablypredicted in the emergency department; therefore, aggressiveresuscitation of near drowning victims shouldbe performed. Decisions to subsequently withdraw lifesupport should be made based on integration of likelihoodof survival, high (but not absolute) certainty, andparental/societal issues. The vegetative patients are themost expensive to care for, while intact survivors are leastexpensive. Reduction of expenditures on patients likelyto have vegetative or dead outcome would result in substantialsavings, but loss of normal survivors. Pediatrics1997;99:715–721; drowning, child, prognosis, outcome,cost.ABBREVIATIONS. ED, emergency department; CPR, cardiopulmonary
- CALIFORNIAABSTRACT. Objective. Predictive efforts using individualfactors or scoring systems do not adequately identifyall intact survivors, and therefore all drowning victimsare aggressively resuscitated in most emergencydepartments. More reliable outcome prediction is neededto guide early treatment decisions.Methods. The charts of 274 near drowning patientsadmitted to Loma Linda University Children’s Hospitalwere retrospectively reviewed. Patient outcome was categorizedinto good (near normal function), and poor (vegetativeor dead) categories. Discriminant analysis wasused to identify combinations of variables most able topredict outcome and a clinical classification system wasconstructed. The acute care hospital costs for each groupwere compared.Results. Discriminant analysis classification achieved95% accuracy, predicting death in 6 intact survivors. Nocombination of variables could accurately separate allintact survivors from the vegetative and dead groups.The clinical classification method achieved 93% overallaccuracy, predicting death in 5 intact survivors. Of patientspredicted to have a poor outcome, 5 (6.3%) survivedintact. Children may experience an unpredictable, prolongedvegetative state followed by full recovery. Vegetativepatients are the most expensive to care for (consuming53% of total costs) while intact survivors are theleast expensive. The majority of costs were spent onpatients with poor outcome.Conclusions. Individual outcome cannot be reliablypredicted in the emergency department; therefore, aggressiveresuscitation of near drowning victims shouldbe performed. Decisions to subsequently withdraw lifesupport should be made based on integration of likelihoodof survival, high (but not absolute) certainty, andparental/societal issues. The vegetative patients are themost expensive to care for, while intact survivors are leastexpensive. Reduction of expenditures on patients likelyto have vegetative or dead outcome would result in substantialsavings, but loss of normal survivors. Pediatrics1997;99:715–721; drowning, child, prognosis, outcome,cost.ABBREVIATIONS. ED, emergency department; CPR, cardiopulmonary
- CALIFORNIAABSTRACT. Objective. Predictive efforts using individualfactors or scoring systems do not adequately identifyall intact survivors, and therefore all drowning victimsare aggressively resuscitated in most emergencydepartments. More reliable outcome prediction is neededto guide early treatment decisions.Methods. The charts of 274 near drowning patientsadmitted to Loma Linda University Children’s Hospitalwere retrospectively reviewed. Patient outcome was categorizedinto good (near normal function), and poor (vegetativeor dead) categories. Discriminant analysis wasused to identify combinations of variables most able topredict outcome and a clinical classification system wasconstructed. The acute care hospital costs for each groupwere compared.Results. Discriminant analysis classification achieved95% accuracy, predicting death in 6 intact survivors. Nocombination of variables could accurately separate allintact survivors from the vegetative and dead groups.The clinical classification method achieved 93% overallaccuracy, predicting death in 5 intact survivors. Of patientspredicted to have a poor outcome, 5 (6.3%) survivedintact. Children may experience an unpredictable, prolongedvegetative state followed by full recovery. Vegetativepatients are the most expensive to care for (consuming53% of total costs) while intact survivors are theleast expensive. The majority of costs were spent onpatients with poor outcome.Conclusions. Individual outcome cannot be reliablypredicted in the emergency department; therefore, aggressiveresuscitation of near drowning victims shouldbe performed. Decisions to subsequently withdraw lifesupport should be made based on integration of likelihoodof survival, high (but not absolute) certainty, andparental/societal issues. The vegetative patients are themost expensive to care for, while intact survivors are leastexpensive. Reduction of expenditures on patients likelyto have vegetative or dead outcome would result in substantialsavings, but loss of normal survivors. Pediatrics1997;99:715–721; drowning, child, prognosis, outcome,cost.ABBREVIATIONS. ED, emergency department; CPR, cardiopulmonary
- Objectives: To describe a large cohort of children with out-ofhospitalcardiac arrest with return of circulation and to identifyfactors in the early postarrest period associated with survival.These objectives were for planning an interventional trial oftherapeutic hypothermia after pediatric cardiac arrest.Methods: A retrospective cohort study was conducted at 15Pediatric Emergency Care Applied Research Network clinical sitesover an 18-month study period. All children from 1 day (24 hrs) to18 yrs of age with out-of-hospital cardiac arrest and a history ofat least 1 min of chest compressions with return of circulation forat least 20 mins were eligible.Measurements and Main Results: One hundred thirty-eightcases met study entry criteria; the overall mortality was 62% (85 of138 cases). The event characteristics associated with increasedsurvival were as follows: weekend arrests, cardiopulmonary resuscitationnot ongoing at hospital arrival, arrest rhythm not asystole, noatropine or NaHCO3, fewer epinephrine doses, shorter duration ofcardiopulmonary resuscitation, and drowning or asphyxial arrestevent. For the 0- to 12-hr postarrest return-of-circulation period,absence of any vasopressor or inotropic agent (dopamine, epinephrine)use, higher lowest temperature recorded, greater lowest pH,lower lactate, lower maximum glucose, and normal pupillary responseswere all associated with survival. A multivariate logisticmodel of variables available at the time of arrest, which controlled forgender, age, race, and asystole or ventricular fibrillation/ventriculartachycardia anytime during the arrest, found the administration ofatropine and epinephrine to be associated with mortality. A secondmodel using additional information available up to 12 hrs after returnof circulation found 1) preexisting lung or airway disease; 2) anetiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateralreactive pupils to be associated with lower mortality. Receiving morethan three doses of epinephrine was associated with poor outcomein 96% (44 of 46) of cases.Conclusions: Multiple factors were identified as associatedwith survival after out-of-hospital pediatric cardiac arrest withthe return of circulation. Additional information available within afew hours after the return of circulation may diminish outcomeassociations of factors available at earlier times in regressionmodels. These factors should be considered in the design offuture interventional trials aimed to improve outcome after pediatriccardiac arrest. (Crit Care Med 2011; 39:141–149)KEY WORDS: cardiac arrest; out of hospital; return of circulation;children; pediatric; cohort study; mortality; outcome; ther
- Neurophysiological monitoring in adult and pediatric intensive care.Amantini A, Carrai R, Lori S, Peris A, Amadori A, Pinto F, Grippo A.SourceClinical Neurophysiology, Neuroscience Department, Careggi Teaching Hospital, Florence, Italy. aldo.amantini@unifi.itAbstractClinical neurophysiology is both an extension of clinical examination and an integration of neuroimaging. It plays a role in diagnosis, prognosis and monitoring in the Intensive Care Unit (ICU). Electroencephalography (EEG) and somatosensory evoked potentials (SEPs) are the most informative neurophysiological tests. Both have a major prognostic role in the hypoxic-ischemic encephalopathy and traumatic brain injury (TBI). In the former the absence of bilateral cortical SEPs has an unfavorable prognostic significance of 100%, whereas bilateral normal SEPs has uncertain prognostic value. In TBI these SEP patterns have high early prognostic value for both bad and good outcome. Continuous EEG monitoring is indicated for diagnosis and treatment of non convulsive seizures and status epilepticus (NCSE), whereas SEPs are more able to indicate the occurrence of neurological deterioration. In our opinion EEG-SEP monitoring is also valuable for interpretation and management of ICP trends, contributing to optimise treatment in a single patient. The EEG seems to have the same prognostic utility in pediatric as in adult ICU. Recent reviews supported the use of SEPs in the integrated process of outcome prediction after acute brain injury in children. However differences in interpretation are needed and the issue is whether it is possible to establish an age limit over which the prediction of SEPs is similar to that in adults. There are only a few studies of seizure prevalence in pediatric ICU. The variability of frequency of NCSE in comatose children is high as in adults and, similar to the adult, remains unclear the impact on outcome.
- Survival after prolonged submersion with hypothermia is well documented1,2Heat loss can be rapidLarge SA to volume ratioCold fluid in lungs (excellent heat exchangers)Apnoea with prolonged periods of sustained cardiac output possibleHypothermia reduces oxygen consumptionapproximately 7% per degree Celcius drop in body temperature1. Kvittingen TT, Naess A, BMJ 19632. Orlowski JP, JAMA 1988FINLANDGroup created a near drowning severity index48 pts11 female, 37 maleLooked at duration of submersion and water tempMedian time 0.5-90 minsAge avg 3.7 0-37 degrees, avg 16 degreesEffect of potentially beneficial rapiddev of hypothermia could not be proved
- FINLANDGroup created a near drowning severity index48 pts11 female, 37 maleLooked at duration of submersion and water tempMedian time 0.5-90 minsAge avg 3.7 0-37 degrees, avg 16 degreesEffect of potentially beneficial rapiddev of hypothermia could not be proved
- The target organ of submersion injury is the lung. Aspiration of as little as 1-3 mL/kg of fluid leads to significantly impaired gas exchange. Injury to other systems is largely secondary to hypoxia and ischemic acidosis. Additional CNS insult may result from concomitant head or spinal cord injury.Fluid aspirated into the lungs produces vagally mediated pulmonary vasoconstriction and hypertension. Freshwater moves rapidly across the alveolar-capillary membrane into the microcirculation. Freshwater is considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Destruction of surfactant produces alveolar instability, atelectasis, and decreased compliance, with marked ventilation/perfusion (V/Q) mismatching. As much as 75% of blood flow may circulate through hypoventilated lungs.Saltwater, which is hyperosmolar, increases the osmotic gradient and therefore draws fluid into the alveoli, diluting surfactant (surfactant washout). Protein-rich fluid then exudates rapidly into the alveoli and pulmonary interstitium. Compliance is reduced, the alveolar-capillary basement membrane is damaged directly, and shunting occurs. This results in rapid induction of serious hypoxia.Fluid-induced bronchospasm also may contribute to hypoxia. The distinction between fluid type is somewhat academic and primarily of epidemiologic importance, as the initial treatments are similar.Pulmonary hypertension may occur secondary to inflammatory mediator release. In a minor percentage of patients, aspiration of vomitus, sand, silt, stagnant water, and sewage may result in occlusion of bronchi, bronchospasm, pneumonia, abscess formation, and inflammatory damage to alveolar capillary membranes.Postobstructive pulmonary edema following laryngeal spasm and hypoxic neuronal injury with resultant neurogenic pulmonary edema may also play roles. Acute respiratory distress syndrome (ARDS) from altered surfactant effect and neurogenic pulmonary edema commonly complicate drowning in survivors.Commonly, these edematous, noncompliant lungs may be further compromised by ventilator-associated lung injury (VALI). Newer modes of ventilation, including high-frequency oscillatory ventilation and airway pressure release ventilation, or an open-lung approach that limits tidal volumes to 6-8 mL/kg while using positive end-expiratory pressure (PEEP) to support optimal respiratory compliance, can help support oxygenation and ventilation with less risk of VALI than is associated with older methods of ventilation.Pneumonia is a rare consequence of submersion injury and is more common with submersion in stagnant warm and fresh water. Uncommon pathogens, including Aeromonas, Burkholderia, and Pseudallescheria, cause a disproportionate percentage of cases of pneumonia. Because pneumonia is uncommon early in the course of treatment of submersion injuries, the use of prophylactic antimicrobial therapy has not proven to be of any benefit.Chemical pneumonitis is a more common sequela than pneumonia, especially if the submersion occurs in a chlorinated pool or in a bucket containing a cleaning product.
- Cold diuresis
- Rectal / oesophageal probesFluids: don’t warm upHumidified O2 greatWarm blanketsPleural One ant and up the other post and down
- In the paediatric population, submersion injury with drowning or near-drowning represents a significant cause of morbidity andmortality. This study reviews retrospectively our own experiences and the literature on the use of cardiopulmonary bypass (CPB)to rewarm paediatric victims of cold water submersion who suffer severe hypothermia (28 °C) and cardiac arrest (asystole orventricular fibrillation). In addition to three children treated at our institution, nine other victims were found in the literature. Inthis cohort of 12 children aged between 2 and 12 years, there was a tendency to better outcome with lower core temperature atthe beginning of extracorporeal circulation (mean temperature in nine survivors, 20 °C; in three non-survivors, 25.5 °C). Thelowest temperature survived was 16 °C. Neither base excess, pH nor serum potassium levels were reliable prognostic factors. Thelowest base excess in a survivor was −36.5 mmol/l, the lowest pH 6.29. We consider CPB as the method of choice forresuscitation and rewarming of children with severe accidental hypothermia and cardiac arrest (asystole or ventricular fibrillation).Compared with adults, children, especially smaller ones, require special consideration with regard to intravenous cannulation asdrainage can be inadequate using femoral–femoral cannulation. In hypothermic children we advocate, therefore, emergencymedian sternotomy. Until more information regarding prognostic factors are available, children who are severely hypothermic andclinically dead after submersion in cold water—even if for an unknown length of time—should receive cardiopulmonaryresuscitation (CPR) and be transported without delay to a facility with capabilities for CPB instituted via a median sternotomy.© 2002 Elsevier Science Ireland Ltd. All rights reserved.Keywords: Near-drowning; Hypothermia; Cardiac arrest; Paediatric resuscitation; Cannulation; CardiopulmonaryPresented at an ECMO conference in Boston: Brompton, Boston / GottingenAbstract: Drowning and near-drowning is often associatedwith severe hypothermia requiring active core rewarming.We performed rewarming by cardiopulmonary bypass(CPB). Between 1987 and 2007, 13 children (9 boys and 4girls) with accidental hypothermia were rewarmed byextracorporeal circulation (ECC) in our institution. Theaverage age of the patients was 3.2 years.Resuscitation wasstarted immediately upon the arrival of the rescue teamand was continuously performed during the transportation.All patients were intubated and ventilated. Core temperatureat admission ranged from 20 to 29°C (mean 25.3°C).Connection to the CPB was performed by thoracic (9patients) or femoral/iliac means (4 patients). Restoration ofcirculation was achieved in 11 patients (84.6%). After CPBtermination two patients needed an extracorporeal membraneoxygenation system due to severe pulmonary edema.Five patients were discharged from hospital after prolongedhospital stay. During follow-up, two patients died(10 and 15 months, respectively) of pulmonary complicationsand one patient was lost to follow-up. The tworemaining survivors were without neurological deficit.Modes of rewarming, age, sex, rectal temperature, andserum electrolytes did not influence mortality. In conclusion,drowning and near-drowning with severe hypothermiaremains a challenging emergency. Rewarming by ECCprovides efficient rewarming and full circulatory support.Although nearly half of the children may survive afterrewarming by ECC, long-term outcome is limited by pulmonaryand neurological complications. KeyWords: Extracorporealcirculation—Pediatric—Near-drowning—AcThere is a lack of data on the outcome ofcardiopulmonary bypass (CPB) rewarming of hypothermicchildren with cardiac arrest following drowning.Aim of the study: To retrospectively analyze single-centeroutcome of drowning victims treated with CPB.Materials and methods: This retrospective study includedall hypothermic drowning victims admitted to the Hospitalfor Children and Adolescents with attempted resuscitationon CPB between 1994 and 2008 inclusive. Mediansternotomy and cannulation of the ascending aorta andthe right atrium for CPB were performed on all victims.Results: Nine hypothermic drowning victims, comprisingfive boys and four girls, with a median age of 3.8 years(range, 1.5–10 years). The median submersion time was38 min (range, 5–75 min) and the median water temperaturewas 6.5 1C (range, 0.2–16.5 1C). The median coretemperature was 21.9 1C (range 17.7–32.8 1C) at arrival tothe hospital. All nine children were able to be weaned fromCPB. Only one child, with mild to moderate neurologicaldeficit, became a long-term survivor. She was slowlyrewarmed up to 33 1C with CPB and kept in mild hypothermiafor 48 h.Conclusions: Large numbers of submergedchildrencanbeprimarilyresuscitated with CPB. Unfortunately, many ofthemwilldecease from severehypoxicbraininjury. Slowrewarming with CPB mayimprove the likelihood of abetterneurologicaloutcome.
- 2.5 yrs20 min since visual contactBystander CPRT 27.33 doses epipH 6.68GCS 3Actively warmedInotrope / pressor dependentSurfactant: resp alkalosis and pneumothoraxExtubated D8No neurodevsequelae
- 2.5 yrs20 min since visual contactBystander CPRT 27.33 doses epipH 6.68GCS 3Actively warmedInotrope / pressor dependentSurfactant: resp alkalosis and pneumothoraxExtubated D8No neurodevsequelae
- 348 Pediatr Crit Care Med 2012 Vol. 13, No. 3EditorialsIs salt water drowning therapeutic in pediatric respiratory failure?*“The dry lung is a happylung” is a mantra espousedfor years bypulmonologists, andpresumably finally embraced by intensivistsafter the 2005 publication of theAcute Respiratory Distress SyndromeNetwork Fluid and Catheter TherapyTrial (FACTT) demonstrating the benefitof conservative relative to liberal fluidmanagement in acute lung injury/acuterespiratory distress syndrome (1). Whilethe trial was negative with regard to theprimary outcome of mortality, it wasconvincingly positive in demonstratingimproved oxygenation, decreased timeon mechanical ventilation, and shortenedintensive care unit stay with conservativefluid management. Perhaps because thestudy was an “adult study,” however, pediatricintensivists appear to be slow inadopting the “dry-lung” strategy. Thestudy by Arikan and colleagues (2) in thisissue of Pediatric Critical Care Medicineoffers a cogent argument why pediatricintensivists should critically appraisetheir approach to fluid management inrespiratory failure.In a single-center study at TexasChildren’s Hospital, Dr. Arikan and colleaguesretrospectively analyzed fluidmanagement in 80 children requiringmechanical ventilation for >24 hrs duringa period from September 2004 to May2005. Most were children with primaryrespiratory failure (63%) or nonpulmonaryinfections (16%). There was a strongassociation between daily fluid balance(quantitated as % fluid overload) andpeak and daily oxygenation index. Higherpeak % fluid overload was associated withlonger durations of ventilation, and pediatricintensive care unit and hospital stay,even when controlling for severity of illnessusing daily pediatric logistic organdysfunction scores. Peak % fluid overloadvalues were also higher in nonsurvivors,although the differences were not statisticallysignificant. Interesting from a therapeuticperspective, most reached theirpeak level of fluid overload 3 days or laterinto their pediatric intensive care unitadmission (Fig. 1 in [2]), suggesting fluidoverload continued after their initial fluidresuscitation.There are obvious limitations to thisstudy. Because of its retrospective natureit is not possible to discern whether fluidoverload resulted from the need for ongoingfluid resuscitation due to “leaky”lungs (endothelial dysfunction), or if lungfunction was compromised due to overlygenerous fluid administration. The authors’correction for “severity of illness”using the pediatric logistic organ dysfunctionscore is also somewhat suspect, giventhat two of the pulmonary variables (Pao2/Fio2 ratio and use of mechanical ventilation)are not independent of the primaryoutcome, and the central nervous systemscore reliability is compromised by theneed to sedate ventilated children (3). Weare left with a strong association between“fluid overload” and lung dysfunction,but not whether they are causally related.Should we give more or less fluid in respiratoryfailure?Like the famous beer commercialarguing “less filling” vs. “more flavor,”dichotomizing overly simplifies thequestion. The question is not “how muchfluid to give,” but rather “when to givehow much fluid.” Three things are true:1) lung inflammation results in capillaryleak (4); 2) cardiac output requiresadequate intravascular volume; and 3)lung water (and thus lung dysfunction)increases in direct proportion to venouspressure in the presence of pulmonaryendothelial injury (5). Because intensivistsare generally more focused on theresuscitative aspects of care, we tendto err on the side of continuing aggressivefluid resuscitation early on becausepulmonary edema is more easily managedthan renal or other end-organ failureconsequent to inadequate cardiacoutput. This does not mean this has tocontinue once hemodynamic stabilityhas been achieved. While the daily fluidbalance is not given in the paper, Figure1 from Arikan et al suggests that many oftheir patients reached their “peak fluidoverload” 5 or 6 days after admission—that is, patients received fluid in significantexcess of their output for severaldays after they likely achievedhemodynamic stability. Data from ourCalfactant in Acute Respiratory DistressSyndrome Trial look quite similar inthat subjects continued to receive fluidin excess of output for the first 7 daysafter entry into the trial (unpublisheddata).Fluid resuscitation in acute illnessis vital (6, 7). Additionally, changes inhemodynamics with the initiation ofpositive pressure ventilation may necessitatefurther fluid administration (8).Consequently, a positive fluid balancein the early course of acute respiratoryfailure is (probably) therapeutic and notunexpected. In the FACTT Trial, subjectswere fluid resuscitated before entry intothe trial and were, on average, nearly 3 Lfluid ahead before randomization. Onlyafter subjects were stabilized, an averageof 41–43 hrs after intensive care unit admission,were they randomized to conservativevs. liberal fluid management. Oncestabilized, the results of the FACTT Trialsupport a more conservative approach tofluid management. By day 2, subjects inthe conservative group were fluid negative,but this was, on average, 72 hrs intotheir illness.The data of Arikan and colleagues suggestthat excessive fluid administrationmay be associated with lung dysfunctionand result in a longer ventilator courseand length of hospital stay. This is consistentwith the findings of the FACTT Trial.Even if we accept these findings as gospel,however, the relevant questions arewhen and how severely to restrict fluidsin respiratory failure, what parametersto follow to guide fluid therapy, and howaggressive to be with diuretics (or whetherto use diuretics at all). These questionscan only be adequately addressedin a prospective trial. Given the routine*See also p. 253.Key Words: acute lung injury; diuretics; fluid balance;fluid overload; pulmonary edema; respiratoryfailure.The author has not disclosed any potential conflictsof interest.Copyright © 2012 by the Society of Critical CareMedicine and the World Federation of Pediatric Intensiveand Critical Care SocietiesDOI: 10.1097/PCC.0b013e31822f159dPediatr Crit Care Med 2012 Vol. 13, No. 3 349nature of fluid administration in pediatricrespiratory failure and the impact offluid administration on the course of mechanicalventilation evidenced by thesedata, such a prospective study would bestrongly supported by the pediatric criticalcare community.Douglas F. Willson, MDPediatrics and AnesthesiaUniversity of Virginia Children’sHospitalCharlottesville, VAREFERENCES1. National Heart, Lung, and Blood InstituteAcute Respiratory Distress Syndrome (ARDS)Clinical Trials Network, Wiedemann HP,Wheeler AP et al: Comparison of two fluidmanagementstrategies in acute lung injury.N Engl J Med 2006; 354:2564–25752. Arikan AA, Zappitelli M, Goldstein SL, et al:Fluid overloadisassociatedwithimpairedoxygenation and morbidity in criticallyillchildren. Pediatr Crit Care Med 2012;13:253–2583. Leteurtre S, Martinot A, Duhamel A, et al:Validationofthepaediatriclogistic organdysfunction (PELOD) score: Prospective, observational,multicentre study. Lancet 2003;362:192–1974. Ware LB, Matthay MA: Theacuterespiratorydistress syndrome. N Engl J Med 2000;342:1334–13495. Sibbald WJ, Short AK, Warshawski FJ, et al:Thermaldyemeasurementsofextravascularlungwater in criticallyillpatients. IntravascularStarlingforces and extravascularlungwater intheadultrespiratorydistress syndrome. Chest1985; 87:585–5926. Rivers E, Nguyen B, Havstad S, et al: Earlygoal-directedtherapy in thetreatmentof severesepsis and septicshock. N Engl J Med2001; 345:1368–13777. Han YY, Carcillo JA, Dragotta MA, et al:Early reversalofpediatric-neonatalsepticshock by communityphysiciansisassociatedwithimprovedoutcome. Pediatrics2003;112:793–7998. Cournand A, Motley HL, Werko L, et al:Physiologicalstudiesoftheeffectsofintermittentpositive pressurebreathing on cardiac outputin man. Am J Physiol1948; 152:162–174Norepresentationwithouttaxation: Declarationof (load)independence in septiccardiomyopathy*We hold thesetruthstobeself-evident: thatmyocardialdysfunctioniscentraltosepsispathophysiologyand, in a septicpatientrequiring multiplevasoactiveinfusions, a cardiologistwill reporttheejectionfractiontobe“good.”In this issue of the Pediatric CriticalCare Medicine, Basuandcolleagues (1)demonstratethatestimates of ejectionfractionandfractionalshortening in 15childrenreceivinginotropic support afterfluidresuscitationfor sepsis wereindistinguishablefromcontrols.At first sight, this is inconsistentwithourunderstandingthatmyocardialdysfunction is a critical element of theclinicalsyndrome of sepsis-inducedmultiorganfailure, and the keycause of earlydeath (2, 3). Afterall, randomized trialsin septic adultsandchildren support theefficacy of structured, early goal-directedresuscitationalgorithms, which targetthe indirect markers of globalperfusion:lactate clearance or superior cavalveinoxygensaturations (4–6). These algorithmsexploit the Frank-Starlingrelationshipsbetweenpreload, contractility,andstroke volume toincreasecardiacoutput (CO) (andoxygen delivery) withfluidresuscitation, bloodtransfusions,andcatecholamines. The impressivereductionsin mortalityseen in these studieswouldbeverydifficulttounderstandifmyocardialfunctiontruly was normalin sepsis.And, of course, myocardialfunction isnotnormal in sepsis. Suffredini et al (7)subjected adult volunteerstointravenousendotoxinandobserveddeclines in ejectionfractionandleftventricularstrokework. Ventricular end-diastolic volumesrose (the heartgotbigger) andhencestroke volume was maintaineddespitereducedcontractility. An increasedheartrate in combinationwith a maintainedstroke volume meantthat CO was typicallysupranormal. Simply put: in sepsis,a biggerheartcontractslessforcefully,more often. Thisdilationshouldprobablybeconsidered a beneficial, andperhapseven a necessary, adaptationfor survival(8). Similarly, reducedcontractilitymayrepresent the cardiomyocytes’ attemptsat self-preservation (9). The septic heartalsorelaxesabnormallyslowly – so-called“diastolicdysfunction” (7).The confusionarisesfromhow wechoosetodescribecardiacfunction.The missing element in this approachof representingcardiacfunctionbyejectionfraction, CO, or similarmeasures isthattheyprovide no adjustmentfor thedegree of “taxation” – the loadingconditionsunderwhich the heart is attemptingtofunction. Systemicvascularresistance(SVR) is oftenreduced in sepsis (7, 10,11). Indeed, the low afterload state ofvasomotor paralysispredominates inadult sepsis, facilitating the increase in*See also p. 259.Key Words: echocardiography; myocardial contraction;pediatrics; sepsis; shockThe authors have not disclosed any potential conflictsof interest.Copyright © 2011 by the Society of Critical CareMedicine and the World Federation of Pediatric Intensiveand Critical Care SocietiesDOI: 10.1097/PCC.0b013e31823886a8Table 1. Echocardiography measures of myocardialperformanceLoad-dependent variablesEjection fraction (msecs) = (LV end-diastolicarea − LV end-systolic area)/LV end-diastolicareaCardiac index: cardiac output (L/min/m2) =(heart rate Å~ stroke volume)/body surfaceareaStroke volume (mL) = time velocity integral cross-sectional areaMyocardial performance index = (isovolumiccontraction time + isovolumic relaxationtime)/ejection timeS wave (tissue Doppler imaging)Load-independent variablesVelocity of circumferential fiber shorteningPreload-adjusted maximal power and preloadadjustedpeak powerMaximal elastancePreload recruitable stroke work maximum rateof left ventricular pressure rise to the enddiastolicvolume, corrected for end-diastolicvolume (mm Hg/sec/ cm3)LV, left ventricular.
- SummaryBackground On the basis of mixed results from previous trials, we assessed whether therapeutic hypothermia for48–72 h with slow rewarming improved mortality in children after brain injury.Methods In this phase 3, multicenter, multinational, randomised controlled trial, we included patients with severetraumatic brain injury who were younger than 18 years and could be enrolled within 6 h of injury. We used a computergeneratedrandomisation sequence to randomly allocate patients (1:1; stratified by site and age [<6 years, 6–15 years,16–17 years]) to either hypothermia (rapidly cooled to 32–33ÅãC for 48–72 h, then rewarmed by 0.5–1.0ÅãC every12–24 h) or normothermia (maintained at 36.5–37.5ÅãC). The primary outcome was mortality at 3 months, assessedby intention-to-treat analysis; secondary outcomes were global function at 3 months after injury using the Glasgowoutcome scale (GOS) and the GOS-extended pediatrics, and the occurrence of serious adverse events. Investigatorsassessing outcomes were masked to treatment. This trial is registered with ClinicalTrials.gov, number NCT00222742.Findings The study was terminated early for futility after an interim data analysis on data for 77 patients (enrolledbetween Nov 1, 2007, and Feb 28, 2011): 39 in the hypothermia group and 38 in the normothermia group. We detectedno between-group diff erence in mortality 3 months after injury (6 [15%] of 39 patients in the hypothermia group vstwo [5%] of 38 patients in the normothermia group; p=0.15). Poor outcomes did not diff er between groups (in thehypothermia group, 16 [42%] patients had a poor outcome by GOS and 18 [47%] had a poor outcome by GOS-extendedpaediatrics; in the normothermia group, 16 [42%] patients had a poor outcome by GOS and 19 [51%] of 37 patientshad a poor outcome by GOS-extended paediatrics). We recorded no between-group diff erences in the occurrence ofadverse events or serious adverse events.Interpretation Hypothermia for 48 h with slow rewarming does not reduce mortality of improve global functionaloutcome after paediatric severe traumatic brain injury.
- ReaSONS TO BE CIRCUMSPECTFever common, bad for injured brain, often not controlled to normothermia in control armsTH does have risks : bleeding, pneumonia, sepsis, arrhythmiasTwo large retrospective studies in paed cardiac arrest (Pittsburgh n=181, CCTG n=222) have not shown benefitData on early prophylactic use of TH in TBI in children suggesting a worse outcome