Evidence Base Medicine Newborn and Child Dominique Biarent Hôpital Universitaire des Enfants Urgences et Soins Intensifs
Consensus on Sciences and Treatment Recommendations http://www.c2005.org/presenter.jhtml?identifier=3022512 Your Guide to the 2005 International CoSTR Conference What is the purpose of the evidence evaluation process? The endpoint of this process is the preparation of the International Consensus on CPR and ECC Science with Treatment Recommendations.
What is the purpose of the International CoSTR Conference? ILCOR is conducting systematic reviews and updates of scientific evidence supporting ECC treatment recommendations. More than 300 CPR and ECC scientific topics 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 organizations American 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.
C2005 Evidence Evaluation Worksheets « Vasopressine leads to better outcome from pediatric cardiac arrest than epinephrine »
Level of Evidence (LOE)
Vasopressin and cardiac arrest, children, ventricular fibrillation , resuscitation, asystole and 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
Supporting evidence table denotes key article Quality of Evidence Underlined: peds Quality of Evidence Excellent Wenzel 2004 ABC (Nolan 2004 ) Mayr 2001 AE Voelckel 2002 E Good Lindner 1997 A Ito 2004 E Lindner 1992 E Lindner 1996a E Fair Morris 1997 E Lindner 1996b ABCD Mann 2002 ABCD Voelckel 2000b B Paradis 1993 E 1 2 3 4 5 6 7 8 Level of Evidence A = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event C = Survival to hospital discharge D = Intact neurological survival ²E = Other endpoint Supporting evidence Vasopressin leads to better outcome from paediatric cardiac arrests than epinephrine
denotes key article Quality of Evidence Neutral/opposing evidence table Neutral/opposing evidence table Excellent Stiell 2001 ABCD Kono 2002 AB Voelckel, 2000c AE Good Biondi-Zoccai 2003A Fair Voelckel 2000b A 1 2 3 4 5 6 7 8 Level of Evidence A = Return of spontaneous circulation C = Survival to hospital discharge B = Survival of event C = Survival to hospital discharge D = Intact neurological survival ²E = Other endpoint Neutral / Opposing evidence Vasopressin leads to better outcome from paediatric cardiac arrests than epinephrine
Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, 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
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 Additional epinephrine w/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 discharge H discharge after 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% AVP Wenzel 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)
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 g/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)
High dose versus low dose adrenaline
« High dose of adrenaline is harmful in children with in-hospital and out-of-hospital cardiac arrest »
209 articles excluded
40 articles analysed : 25 human and 15 animal model studies
« The recommended resuscitation dose of adrenaline for children (0.01 mg/kg) should be increased
Age less than 18 years
5 articles met full criteria
Goetting MG, Paradis NA. High dose epinephrine in refractory pediatric cardiac arrest. Crit Care Med. 1989;17:1258-62
7 children received 0.2 mg/kg adre : 6 ROSC Compared to 20 historic controls (SDE): no ROSC
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 historic control group (20 in each). HDE : 14 ROSC (70%), 8 long term survival, 3 intact
Refractory CA is > 2 doses of adrenaline
No difference in survival at discharge
Compression / Ventilation Ratio
A universal compression-ventilation ratio should be used for infants and children irrespective of their age, etiology of arrest and number of rescuers
Scientific evidence supports the superiority of a 5:1 CV ratio in children rather than the 15:2 CV ratio recommended for adults
20 articles used for discussion
9 articles in grid
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
Rescue breathing is critically important for asphyxial arrest (inadequate O2 content and high CO2 in the lungs at the time of CA) 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)
Berg RA, Sanders AB et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for VF cardiac arrest. Circ 2001;104:2465-2470
Interrupting CC for rescue breathing decreases mean coronary perfusion, LV blood flow & number of compression in swine.
Dorph E, Wik L, Steen PA. Effectiveness of ventilation-compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation. Resuscitation. 2002;54:259-64
Same minute ventilation; Better compression with 15:2
Kinney SB, Tibballs J. An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression–ventilation ratios in manikin-simulated paediatric resuscitation. Resuscitation 2000;43:115-120. 84.6 84.6 84.6 % effective chest compression 83.7 78.9 87.9 Total compressions/min 1.4 2.0 2.2 MV 12 17 18 Breaths/min 115 117 121 Tidal volume 15:2 10:2 5:1 C/V ratios
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 34 56 Min 5 47 60 Min 4 40 53 Min 3 41 55 Min 2 59 58 Min 1 Ratio 15/2 Ratio 5/1
Optimum C/V ratios in pediatric basic life support 5 + AGE for Pro 5 + AGE/2 for LAY
Babbs CF, Nadkarni V. Optimizing chest compression to rescue ventilation ratios during one-rescuer CPR by professionals and lay persons: children are not just little adults . Resuscitation 2004;61:173-81.
Oxygen delivery function of C/V ratio
professionally trained rescuers (2 rescue breaths in 5 s)
lay rescuers, (2 rescue breaths in 16 s)
Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical conditions: a physiological and mathematical analysis. Resuscitation. 2002 Aug;54(2):147-57. Blood flow DO2 Blood flow DO2 Alv O2 Alv O2
Optimal combined flow/DO2
For 10 000 simulations OPTIMAL RATIO between 30:2 and 50:2
Simplicity of teaching is crucial
Do we need an universal ratio?
Biphasic defibrillation Number of shocks that failed to terminate the initial VF episode for monophasic weight-based and attenuated adult biphasic shocks in the 4, 14 and 24 kg weight categories. * P <0.01.
ROSC and 4 & 24 h survival Berg RA, Chapman FW et al Attenuated adult biphasic shocks compared with weight-based monophasic shocks in a swine model of prolonged pediatric ventricular fibrillation. Resuscitation 2004, 61: 189-197
Automated External Defibrillator (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
AED in children?
Recommended (Class IIb) for children older than 1 year in the pre-hospital setting (circulation 2003)
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