Okay so it’s a small case series – but the results warrant further investigation: 10-20 mcg/kg terlipressin was given to five infants and children who arrested in the paediatric intensive care unit and who had not responded to several doses of adrenaline (epinephrine)1. Sustained return of spontaneous circulation (ROSC) was achieved in four, and two survived to be discharged home without sequelae and with good neurologic status at 6 and 12 month follow up. Interestingly, the four patients who had ROSC all had septic shock as the cause of their arrest. The two survivors had severe bradycardia and severe bradycarda-asystole as the arrest rhythms, and both received 20 mcg/kg terlipressin.
Terlipressin is a synthetic arginine vasopressin analog with a significantly longer duration of effect, which previously showed positive effects when administered to a small group of children unresponsive to prolonged resuscitative efforts2.
1. Pediatric cardiac arrest refractory to advanced life support: Is there a role for terlipressin?
Pediatr Crit Care Med. 2010 Jan;11(1):139-41
2. Beneficial effects of terlipressin in prolonged pediatric cardiopulmonary resuscitation: A case series.
Crit Care Med. 2007 Apr;35(4):1161-4
Tag Archives: ACLS
Control oxygenation after resuscitation
How much oxygen should we give patients after successful cardiac arrest resuscitation? Too little oxygen may potentiate anoxic injury. Too much oxygen may increase oxygen free radical production, possibly triggering cellular injury and apoptosis. A multicentre ICU database of over 6300 post-arrest patients was analysed and demonstrated an association between ‘hyperoxia’ and in-hospital mortality.
Adult patients who sustained nontraumatic cardiac arrest and were admitted to the ICU at a participating center between 2001 and 2005 were included. Specifically, inclusion criteria were age older than 17 years, nontraumatic cardiac arrest, cardiopulmonary resuscitation within 24 hours prior to ICU arrival, and arterial blood gas analysis performed within 24 hours following ICU arrival.
The cohort was divided into 3 exposure groups defined a priori based on PaO2 on the first arterial blood gas values obtained in the ICU. Hyperoxia was defined as PaO2 of 300 mm Hg (39.5 kPa) or greater; hypoxia, PaO2 of less than 60 mm Hg (7.9 kPa) (or ratio of PaO2 to fraction of inspired oxygen [FIO2] <300); and normoxia, cases not classified as hyperoxia or hypoxia.
Exposure to hyperoxia was found to be a significant predictor of in-hospital death (OR, 1.8 [95% CI, 1.5-2.2]; this was an independent effect that persisted after adjusting for all other significant risk factors
The authors acknowledge that association does not necessarily imply causation, but add that these data support the hypothesis that high oxygen delivery in the postcardiac arrest setting may have adverse effects.
Association Between Arterial Hyperoxia Following Resuscitation From Cardiac Arrest and In-Hospital Mortality
JAMA. 2010;303(21):2165-2171
Post cardiac arrest guideline
A patient is resuscitated from an out-of-hospital cardiac arrest and is in your emergency department, comatose, with a pulse.
You know that therapeutic hypothermia is indicated and are happy with the protocol for that. You clinically assess for the underlying cause with history, examination, ECG, and other investigations as indicated.
Someone asks you if you want to give some magnesium “as per the guidelines”. As you are wondering what that’s for someone else asks you how long myocardial stunning lasts for and whether that’s the likely cause of hypotension now.
Luckily you avoid getting annoyed with all these reasonable questions by suddenly remembering that there are international recommendations for the management of ‘Post–Cardiac Arrest Syndrome’. You excuse yourself from the room on the pretext of going to the lavatory and quickly find a quiet area where you scan the following article for help:
Post–Cardiac Arrest Syndrome Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council
Circulation 2008;118;2452-2483 Full Text Article
PCI and therapeutic hypothermia
Percutaneous coronary intervention did not increase the risk of dysrhythmia, infection, coagulopathy, or hypotension associated with therapeutic hypothermia after cardiac arrest. Intensivists and cardiologists should perhaps agree that this adds to existing evidence that the two therapies are not mutually exclusive.
Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest
Resuscitation. 2010 Apr;81(4):398-403
Hospital bypass for cardiac arrest?
A Japanese study of over 10,000 patients demonstrated improved neurological outcome in out-of-hospital cardiac arrest patients who were taken to hospitals designated as ‘critical care medical centres’, where neurologically favorable 1-month survival was greater [6.7% versus 2.8%, P < 0.001] despite a slightly longer call-hospital arrival interval [30.6 min vs 27.2, p < 0.001]. If return of spontaneous circulation was achieved pre-hospital, there was no difference in survival. It is unclear what factors, such as more interventional cardiology or therapeutic hypothermia, made the difference in the critical care centres.
Impact of transport to critical care medical centers on outcomes after
out-of-hospital cardiac arrest
Resuscitation. 2010 May;81(5):549-54
Distance to hospital did not affect arrest survival
In a study of over 7500 patients with cardiac arrest transported by EMS in the United States, transport distance was not associated with survival on logistic analysis (OR 1.00; 95% CI 0.99–1.01).
A geospatial assessment of transport distance and survival to discharge in out of
hospital cardiac arrest patients: Implications for resuscitation centers
Resuscitation. 2010 May;81(5):518-23
Best position for CPR
A study using volunteer doctors and nurses in simulated cardiac arrest resuscitations compared three different positions for delivering CPR: standing, kneeling by the patient, or standing on a “taboret”. They measured rescuer fatigue and effectiveness of CPR. They conclude that CPR is best performed in a kneeling position in that it maximizes duration of effective chest compression and minimizes back pain. The authors recommend if two or more experienced healthcare providers are available to perform CPR, alternating rescuers every 2 min in the kneeling or standing on a taboret positions, and every 1min in the standing on the floor position in order to minimize rescuer fatigue.
Rescuer fatigue and cardiopulmonary resuscitation positions: A randomized controlled crossover trial
Resuscitation. 2010 May;81(5):579-84
Early CT and post-arrest outcome
A study on the early CT appearances of post-cardiac arrest patients shows two signs to be of importance – loss of boundary (LOB) between white and grey matter (at the level of the basal ganglia), and cortical sulcal effacement (SE). These features were more prevalent in patients who had > 20 minutes of arrest time and were associated with a worse neurological outcome at six months.
Early CT signs in out-of-hospital cardiac arrest survivors: Temporal profile and
prognostic significance
Resuscitation. 2010 May;81(5):534-8
Kids need 'proper' CPR if non-cardiac cause of arrest
The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. These recommendations have new support in a large observational study from Japan examining outcomes in 5170 out-of hospital paediatric arrests over a 3 year period.
For children who had out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander was associated with improved outcomes compared with compression-only CPR (7·2% [45/624] favourable one month neurological outcome vs 1·6% [6/380]; OR 5·54, 2·52–16·99). In children who had arrests of cardiac causes conventional and compression-only CPR were similarly effective. Infants < 1 year had uniformly poor outcomes.
An editorial points out that this is the largest study that has analysed out-of-hospital cardiac arrest in children, and the overall survival of 9% with only 3% of children having a good neurological outcome, is consistent with previous reports.
Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study
Lancet. 2010 Apr 17 345:1347-54
2000 vs 2005 VF guidelines: RCT
One of the key changes in international resuscitation guidelines between the 2000 and 2005 has been to minimise potentially deleterious hands-off time, so that CPR is interrupted less for pulse checks and DC shocks.
These two approaches have been compared in a randomised controlled trial of 845 patients in France requiring out of hospital defibrillation, in which the control group were shocked using AEDs with prompts based on the 2000 guidelines (3 stacked shocks before CPR resumed, and pulse checks done), and the intervention group were shocked using devices that prompted according to the 2005 guidelines, in which there were fewer and shorter intervals for which the AED required the rescuer to stay clear of the patient (single shocks, no pulse checks).
There was no difference in the primary endpoint of survival to hospital admission (43.2% versus 42.7%; p=0.87), or in survival to hospital discharge (13.3% versus 10.6%; p=0.19). The study was not powered to assess one year survival. In the authors’ words: “our randomized controlled trial now provides more definitive evidence that this combination of Guidelines 2005 CPR protocol changes does not measurably improve outcome. Although the protocol changes accomplish the desired effect of increasing chest compressions, they may also cause other effects, such as earlier refibrillation and more time spent in VF, with as yet unknown consequences.”
Interestingly the Cardio-pump was used in this study to provide chest compressions, which is an active compression-decompression device, potentially limiting the generalisability of the findings to manual compression-only CPR situations. Potential bias was also introduced by the exclusion of patients in whom consent from relatives was not obtained. Nevertheless it’s good to see such rigorous clinical research applied to this area.
DEFI 2005. A Randomized Controlled Trial of the Effect of Automated External Defibrillator Cardiopulmonary Resuscitation Protocol on Outcome From Out-of-Hospital Cardiac Arrest
Circulation. 2010;121:1614-1622