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
An interhospital transport service introduced a no infusions policy for patients being transferred for primary coronary intervention, instead giving a bolus of heparin and glycoprotein 2b-3a inhibitor prior to transfer, along with non-intravenous nitrates (if needed). Discontinuing infusions during transport resulted in a significant reduction in transport times with no adverse effect on hospital length of stay or mortality. It did not significantly extend the time the patient spent in the catheterisation laboratory, nor did it impact the incidence of TIMI III flow. It did not impact the incidence of readmission to the hospital for cardiac-related chief complaints.
Transporting without infusions: effect on door-to-needle time for acute coronary syndrome patients
Prehosp Emerg Care. 2010 Apr 6;14(2):159-63
In a randomised noninferiority trial the oral direct thrombin inhibitor dabigatran was compared with warfarin in patients with venous thromboembolic disease (VTE) after acute treatment with parenteral anticoagulation. Recurrent VTE and major bleeding rates were similar in the two groups. Dabigatran has the advantage of not requiring blood monitoring.
Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism
N Engl J Med. 2009 Dec 10;361(24):2342-52
A multicentre double blind trial in 800 infants with bronchiolitis aged between 6 weeks and 12 months compared placebo with nebulised adrenaline, oral dexamethasone, or both. Only the combination led to a decrease in the primary endpoint of reduced hospital admission up to 7 days after enrollment, with an absolute risk reduction of 9% (from 26 to 17%). They also found an apparent benefit from combined therapy on their secondary outcomes: infants in the combined treatment group were discharged earlier from medical care and resumed quiet breathing and normal feeding sooner than did those in the placebo group. When the analysis was adjusted for multiple comparisons, the apparent benefit did not reach statistical significance, leading the authors to recommend further study.
Epinephrine and Dexamethasone in Children with Bronchiolitis
N Engl J Med. 2009 May 14;360(20):2079-89
A very comprehensive (hence the title of the paper) review of medications required for pre-hospital & retrieval medicine missions was undertaken, resulting in recommendations. While the casemix seen by various services may be influenced by local geography or tasking restrictions, the list provides an excellent standard from which locally appropriate modifications can be made.
Defining a standard medication kit for prehospital and retrieval physicians: a comprehensive review.
Emerg Med J. 2010 Jan;27(1):62-71
Hyperoxia may reduce coronary artery blood flow, increase systemic vascular resistance, and decrease cardiac output. This paper argues that if the baseline arterial oxygen saturations are >90%, high concentration oxygen does not increase oxygen transport, as the reductions in cardiac output are in excess of the increase in oxygen content. The balance of the limited evidence that exists suggests that the routine use of oxygen in uncomplicated MI (no failure or shock) may increase infarct size and possibly increase the risk of mortality, owing to its haemodynamic effects, including a reduction in coronary blood flow.
Routine use of oxygen in the treatment of myocardial infarction: systematic review
Heart. 2009 Mar;95(3):198-202
An industry-sponsored double-blind randomised controlled trial comparing midazolam with the central alpha-2 agonist dexmedetomidine showed the newer drug to provide similar levels of sedation with less delirium and a shorter time to extubation. It was associated with more episodes of bradycardia not requiring intervention.
This new sedative drug, related to clonidine, provides some analgesia and anxiolysis, and is noted for its lack of respiratory depression. An accompanying editorial points out the known association between benzodiazepines and delirium, and asks whether a comparison with propofol would have shown the same improved outcomes.
Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial
JAMA. 2009 Feb 4;301(5):542-4
The risk of apnoea in neonates requiring prostaglandin E1 infusions for duct-dependent congenital heart disease is well described and often results in the recommendation to intubate prior to transfer. An American study of 202 transported infants on PGE1 shows a higher rate of transport-related complications in those that had been intubated. None of the 73 (36%) unintubated patients required intubation for apneoa during transport. These data are in keeping with a previous Australian study of 300 infants receiving PGE1 in which only 2 of 78 unintubated patients experienced apnoea.
To intubate or not to intubate? Transporting infants on prostaglandin E1
Pediatrics. 2009 Jan;123(1):e25-30