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Dominique Biarent

Hôpital Universitaire des Enfants

Urgences et Soins Intensifs

Consensus on Sciences andTreatment Recommendations

http://www.c2005.org/presenter.jhtml?identifier=3022512

Your Guide to the 2005 International CoSTR Conference

What is the purpose of the evidence evaluationprocess?The endpoint of this process is the preparationof the International Consensus on CPR and ECC Science with Treatment Recommendations.

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What is the purpose of theInternational CoSTR Conference?

ILCOR is conducting systematic reviews andupdates of scientific evidence supporting ECC

treatment recommendations.

More than 300 CPR and ECC scientifictopics will undergo evidence-based

review

This process represents the most comprehensive, systematic review of the resuscitation literature to

date

Who's in charge?ILCOR - the International Liaison Committee on Resuscitation.includes 7 international resuscitation organizationsAmerican Heart Association (AHA),European Resuscitation Council (ERC),Heart and Stroke Foundation of Canada (HSFC), Resuscitation Council of Southern Africa (RCSA), Australia and New Zealand Council on Resuscitation (ANZCOR), InterAmerican Heart Foundation (IAHF).

Japan Resuscitation Council JRC : international observer to ILCOR.China (Ministry of Health) : international observer to the C2005 Conference.

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C2005 Evidence EvaluationWorksheets

« Vasopressine leads to betteroutcome from pediatric cardiac

arrest than epinephrine »

Level of Evidence (LOE)

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Rating

Direction

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5

Search Strategy• Vasopressin and cardiac arrest, children,

ventricular fibrillation , resuscitation, asystoleand children (MeSH term and textwords)

• Pubmed 244 hits (19 Aug 2004)• Embase141 hits (19 Aug 2004)• Cochrane Library 1 hit (15 Aug 2004)• Update 24 Jan 2005 : 1 hit

������������ ���������

denotes key article

Quality of Evidence

Excellent

Wenzel 2004 ABC(Nolan 2004)

Mayr 2001 AE Voelckel2002 E

Good Lindner 1997 A

Ito 2004 E Lindner 1992 ELindner 1996a E

FairMorris1997 E

Lindner 1996b ABCDMann

2002 ABCD

Voelckel2000b B

Paradis1993 E

1 2 3 4 5 6 7 8

Level of EvidenceA = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event C = Survival to hospital dischargeD = Intact neurological survival ²E = Other endpoint

Qua

lity

of E

vide

nce

Supporting evidenceVasopressin leads to better outcome from paediatric cardiac arrests than epinephrine

Underlined: peds

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denotes key article

Qua

lity

of E

vide

nce

Neutral/opposing evidence table

Excellent Stiell 2001 ABCD

Kono 2002 ABVoelckel, 2000c AE

Good Biondi-Zoccai2003A

Fair

Voelckel2000b A

1 2 3 4 5 6 7 8

Level of EvidenceA = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event C = Survival to hospital dischargeD = Intact neurological survival ²E = Other endpoint

Neutral / Opposing evidenceVasopressin leads to better outcome from paediatric cardiac arrests than epinephrine

������������������ ���������

• Wenzel V, Krismer AC, Arntz HR, Sitter H, StadlbauerKH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350(2):105-13.

• LOE1 excellent RCT (intention to treat)• 1189 patients (no children)• Similar rate of survival to hospital admission for VF

/PEA• Better survival for asystolic patients treated with

vasopressin• In absence of ROSC with study drug, additional

epinephrine improved survival in VP group not in EPI group

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1.7 % 4/10

20.3%1.5%0

30.5% 8.6 %

43%19.2%

EPI

0.3 (0.1-0.6) (p0.002*)

(ns)

6.2 %10/40

H discharge

Intact neurol

Additionalepinephrinew/o ROSC

0.6 (0.4-0.9) (p0.02*)0.3 (0.1-1.0) (p0.04*)

(p0.008*)

29%4.7%3.8%

H admission

H dischargeH dischargeafter epi

ASYSTOLE

0.8 (0.5-1.8)(p0.65)1.4 (0.5-4.7) (p0.47)

33.7%5.9 %

H admission

H discharge

PEA

0.9 (0.6-1.3)(p0.48)1.1 (0.7-1.8) (p0.7)

46.2 %17.8 %

H admission

H discharge

VF

RR–CI 95%

AVPWenzel 2004

• Voelckel WG, Lurie KG, McKnite S, et al. Comparison of epinephrine and vasopressin in a pediatric porcine model of asphyxial cardiac arrest. Crit Care Med 2000;28(12):3777-83.

• Paediatric piglet model of asphyxial arrest• Epi or VP+Epi : higher myocardial BF• VP+Epi : higher cerebral BF• ROSC Epi 6/6* VP+Epi 5/6 VP 1/6• Limitation : use of high dose Epi (200 mcg/kg)

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• Voelckel WG, Lurie KG, McKnite S, et al. Effects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation. Crit Care Med 2002;30(5):957-62.

• Paediatric piglet model of prolonged VF (8 min + 20 min CPR),

• Combination VP (0.8 IU/kg) +Epi (45 µg/kg) : higher left ventricular myocardial blood flow than VP or Epi alone

• VP+Epi and VP alone : higher cerebral blood flow than Epi alone

• ROSC ns VP + Epi 6/6 VP5/6 Epi 2/6.

• Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation 2002;52(2):149-56.� 6 long lasting CA in 4 children after > 2

doses adrenaline� VP as rescue therapy� 3 ROSC (>1h)� 1 withdrawal therapy (>24 h)� 1 survivor

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High dose versus low dose adrenaline

• Author A• « High dose of adrenaline

is harmful in children within-hospital and out-of-hospital cardiac arrest »

• Search strategies• 209 articles excluded• 40 articles analysed : 25

human and 15 animal model studies

• Author B• « The recommended

resuscitation dose ofadrenaline for children (0.01 mg/kg) should be increased

• Search strategies• Age less than 18 years• 5 articles met full criteria

• Goetting MG, Paradis NA. High dose epinephrine in refractory pediatriccardiac arrest. Crit Care Med. 1989;17:1258-62

• 7 children received 0.2 mg/kg adre : 6 ROSC Compared to 20 historic controls (SDE): noROSC

• LOE 5 (fair)

• Goetting MG, Paradis NA. High-dose epinephrine improves outcome from

pediatric cardiac arrest. Ann Emerg Med. 1991;20:22-6.

• Prospective intervention group versus historiccontrol group (20 in each). HDE : 14 ROSC (70%), 8 long term survival, 3 intact

• LOE 3

Refractory CA is > 2 doses of adrenaline

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• No difference in survival at discharge• LOE1 (excellent)

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Compression / Ventilation Ratio

• Author A• A universal compression-

ventilation ratio should beused for infants andchildren irrespective oftheir age, etiology ofarrest and number ofrescuers

• Search strategies• 9 articles

• Author B• Scientific evidence

supports the superiority ofa 5:1 CV ratio in childrenrather than the 15:2 CV ratio recommended for adults

• Search strategies• 20 articles used for

discussion• 9 articles in grid

In children

• Metabolic rates, CO2 production, ventilatory needs are higher in the non-arrest setting

• Pediatric CA are precipitated by asphyxia or shock

• In-hospital HCP are accustomed to a 5:1 rather than 15:2

• time to BLS in asphyxial CA vs Time to defibrillation in VF are crucial

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• Rescue breathing is critically important for asphyxial arrest (inadequate O2 content and high CO2 in the lungs at the time ofCA) but not necessary for VF

• VF has a normal O2 / CO2 content in lungs and hyperventilation is deleterious

• BLS not necessary fort short duration VF• BLS crucial for prolonged duration VF

Evidence Of Science

• Manikin studies or animal studies(LOE 6)

• Mathematical model (LOE 6) SE

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• Berg RA, Sanders AB et al. Adverse hemodynamic effects of interrupting chestcompressions for rescue breathing duringcardiopulmonary resuscitation for VF cardiacarrest. Circ 2001;104:2465-2470

• Interrupting CC for rescue breathingdecreases mean coronary perfusion, LV blood flow & number of compression in swine.

• Dorph E, Wik L, Steen PA. Effectiveness ofventilation-compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation. Resuscitation. 2002;54:259-64

• 1 lay rescuer – child sized manikin – 2 ratios 5:1 or 15:2

• Same minute ventilation; Bettercompression with 15:2

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84.684.684.6% effective chestcompression

83.778.987.9Total compressions/min

1.42.02.2MV

121718Breaths/min

115117121Tidal volume

15:210:25:1C/V ratios

Kinney SB, Tibballs J. An analysis of the efficacy of bag-valve-mask ventilation andchest compression during different compression–ventilation ratios in manikin-simulated paediatric resuscitation. Resuscitation 2000;43:115-120.

J. L. Greingor. Quality of cardiac massage with ratio compression–ventilation 5/1 and 15/2.Resuscitation 2002; 55:263-267

Mean number of correct compression

3456Min 5

4760Min 4

4053Min 3

4155Min 2

5958Min 1

Ratio 15/2Ratio 5/1

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Optimum C/V ratios in pediatric basic life support 5 + AGE for Pro5 + AGE/2 for LAY

• Babbs CF, Nadkarni V. Optimizing chestcompression to rescueventilation ratios during one-rescuer CPR by professionalsand lay persons: children are notjust little adults. Resuscitation2004;61:173-81.

Oxygen delivery function of C/V ratio (a) professionally trained rescuers (2 rescue breaths in 5 s) (b) lay rescuers, (2 rescue breaths in 16 s)

Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practicalconditions: a physiological and mathematical analysis. Resuscitation. 2002 Aug;54(2):147-57.

Blood flow

DO2

Blood flow

DO2

Alv O2Alv O2SE

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Optimal combined flow/DO2

For 10 000 simulations

OPTIMAL RATIO between 30:2 and 50:2

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• Simplicity of teaching is crucial• Do we need an universal ratio?

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Number of shocksthat failed to terminate the initial VF episode for monophasic weight-based andattenuated adultbiphasic shocks in the 4, 14 and 24 kg weight categories. *P<0.01.

Biphasic defibrillation

Berg RA, Chapman FW et al Attenuatedadult biphasic shocks compared withweight-based monophasic shocks in a swine model of prolonged pediatricventricular fibrillation.Resuscitation 2004, 61:189-197

ROSC and 4 & 24 h survival

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Ventricularfunction

Automated ExternalDefibrillator (AED)

• Evaluates the victim’s ECG• Determines if a “shockable” rhythm is present• Charges the “appropriate” dose• When activated by operator, delivers a shock• Provides synthetised voice prompts to assist

the operator

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AED in children?• Experience limited• Recommended (Class IIb) for children older

than 1 year in the pre-hospital setting (circulation 2003)

• Remember:– Most arrests in children are respiratory in origin– The most frequent arrest rhythms are Asystole and

PEA– Prompt defibrillation is the definitive treatment for

VF and pulseless VT– Basic life support sequence

Conclusion

• Ongoing process• Evidence of science• Guidelines• Courses• Evidence Based Medicine

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