Tuesday, March 9, 2021
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In JAMA Pediatrics this past week, there’s a fantastic review of pediatric in-hospital cardiac arrest (IHCA) by my talented PICU colleagues here at the Children’s Hospital of Philadelphia. Morgan et al. reviewed the currently available literature and summarized the characteristics of children who required CPR while hospitalized. They provide important lessons for anesthesia professionals, particularly with regard to the performance of high-quality CPR, and post-arrest care after return to spontaneous circulation (ROSC). The authors make the following important points:
· The location of IHCA seems to be shifting from the regular hospital wards to the PICU, as many institutions have implemented rapid response systems to move tenuous patients to a monitored-care setting;
· Most children with IHCA have progressive respiratory failure or shock;
· The majority of IHCA cases present with bradycardia with poor perfusion, and most of the remaining cases have non-shockable rhythms;
· Among other factors, the quality of the CPR and post-ROSC care correlate with survival.
Principles of high-quality pediatric CPR (see Table 2 in publication):
· Compressions 100-120/minute, should account for at least 80% of total CPR time;
· Be sure to achieve proper depth of compression at least 1/3 AP depth: infants 4 cm, children 5 cm, adolescents 5-6 cm;
· Allow full recoil between compressions to optimize preload, don’t lean;
· If intubated, 10 breaths/min;
· Mask ventilation: 2 breaths per 30 compressions for adolescents, 2 breaths per 15 compressions for infants and children;
· Minimal interruptions.
Principles of post-cardiac arrest therapy (see Table 3 in publication):
· Optimize brain perfusion using antiseizure medications, targeted temperature management, adequate sedation, and keep SpO2 above 94%;
· Avoid cardiac dysfunction using inotropic and antiarrhythmic medications, electrolyte repletion, and mechanical ventilation;
· Minimize the systemic ischemia-reperfusion response using inotropes, insulin/dextrose, corticosteroids, blood products, moderate hypothermia, and renal replacement.
There are many more important principles described in the article for which space here does not allow for discussion. But if you are confronted with the need for CPR in the OR, follow these principles to optimize outcomes prior to transfer to the PICU.