Thread by @ryan_w_morgan

@TiaTiaraymond @AlexisTopjian just announced a big change in the @HeartCPR Pediatric #CPR guidelines...ventilate 20-30 times per minute during CPR in children with an airway in place. Based, in part, on @CritCareMed publication by @SuttonB_ICUMD #PedsICU #CPRsaveslives

Take-home messages:

1. High-quality #CPR is the foundation of resuscitation. New data reaffirm the key components of high-quality CPR: adequate compression rate / depth, minimizing interruptions, allowing full chest recoil between compressions, & avoiding excessive ventilation.

2. A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse.

3. For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive.

DON'T WAIT!

4. Using a cuffed endotracheal tube decreases the need for endotracheal tube changes.

5. The routine use of cricoid pressure does not reduce the risk of regurgitation during bag-mask ventilation and may impede intubation success.

6. For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation.

7. Resuscitation does not end with ROSC. Excellent post-arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous EEG.

7 (cont.). The prevention and/or treatment of post-arrest hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important.

8. After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions.

9. Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest.

Editorial:
1. Need prospective studies of CPR mechanics targets...we are still using and recommending extrapolated guesswork targets...meeting goals is better than not meeting goals but are these targets better than others? Let's test it.

2a. To think about the new vent rates guidelines we need to think about the logic behind former ventilation rate guidelines:
(i) Same as adult guidelines = ease of teaching / learning
(ii) Lower minute ventilation necessary to "match" low cardiac output during CPR.

(iii) Deleterious effects of "over-ventilation" = decreased venous return and decreased cardiac output / coronary perfusion pressure during CPR

2b. Why does a higher rate make sense?
CHILDREN ARE NOT SMALL ADULTS! Higher physiologic respiratory rates (more anatomic dead space = more dependence on RR for minute ventilation) + 70-90% with respiratory etiology of arrest (GOTTA FIX THE PROBLEM!)...

Also...contemporary high-quality CPR likely generates better cardiac output than old lab studies on which our estimates and guidelines are based...we need to study this.

2c. What new data informed the new vent rate guidelines?

journals.lww.com/ccmjournal/Abs…

Multicenter study of 52 ICU CPR events...ZERO events met guideline recommendations (10+/-2 breaths/min). ZERO! Medan rate was 29.8 breaths/min. High rates associated with higher odds of survival.

Lead author @SuttonB_ICUMD will agree with me that while these data are great (and the best we have at the moment) if we are basing our #PALS guidelines on 52 patients, we have a long way to go and need prospective studies! Looking at you @NICHD_NIH @nih_nhlbi ;)

2d. Rates are just the start! We wouldn't let it slide if a resident in the #pedsICU reported a vent rate and nothing else on a patient with #pARDS...so how is it ok when that same patient has a cardiac arrest? Ventilation parameters during #CPR are a black box. @lindsaynshepard

3. Epinephrine...give it when you can give it...don't wait. But, knowledge gaps, oh my...do we really know the ideal dose? dosing interval? when to stop (e.g. during #ECPR cannulation)? when to give more (when the patient "fails to respond")? @MarthaKienzleMD

4. Cuffed endotracheal tubes....let's just take this and apply to (just about) everyone and not just kids getting CPR? #PedsICU #PEM

(makes additional sense with aerosol generation concerns in the #COVID19 era)

5. I have absolutely zero opinions about cricoid pressure.

6. BMV vs ETT vs supraglottic airways in pediatric #OHCA:

jamanetwork.com/journals/jama/…

sciencedirect.com/science/articl…

sciencedirect.com/science/articl…

Globally no different...which I interpret meaning "it depends" rather than "they're no different." Likely depends on personnel type, airway experience, resources, arrest etiology, time to definitive care, etc...

And airway management during pediatric IHCA...."The data are not sufficient to support a recommendation for advanced airway use in IHCA." There is certainly a huge gap between observational studies that suggest harm with intubation and actual provider practice...

7. We attain return of circulation in 80%+++ of pediatric #IHCA events...but less than half of children survive to discharge. Post-resuscitation care matters! Don't let them get hot, too blue, too pink, or too anything else.

Ran out of tweets...#PedsICU #PEM #CPR #PALS