Thread by @PedsIntensiva

3rd regular episode of @pedsintensiva, podcast that bridges the gap btw literature & practice for #pedsICU

CPR & #ECMO in Single V patients w Ravi Thiagarajan Division Chief of Cardiac ICU @bostonchildrens

Tweetorial 👇

tinyurl.com/CPRandECMOsing…

#pedscards #pedsCICU #CHD

@BostonChildrens Single V pts are ++ risk for arrest & #ECMO support

Many pts die & more have morbidity, even in best centers

Prevention of arrest is more important & effective than rescue CPR/ECMO – great work by @pc4quality in making prevention sexy!

#pedsICU #pedscards #pedsCICU #CHD

@BostonChildrens @pc4quality ECPR (extracorporeal-CPR) is only ever as good as the CPR you get beforehand

Getting a pt onto #ECMO is busy but don’t forget the prime importance of good quality CPR w minimal interruptions on the way there

#pedsICU #pedscards #pedsCICU #CHD

@BostonChildrens @pc4quality Chest pressy pressy & air inny outy is just as important as the fancy #ECMO you're trying to start for ECPR

Even less fancy & FAR more effective is preventing the whole situation by identifying risky patients and preventing them arresting

#pedsICU #pedscards #pedsCICU #CHD

@BostonChildrens @pc4quality #ECMO vital support for #pedscards surgical program (esp. complex) & can rescue 1/3 patients in whom death otherwise certain

As w other areas prevention & rescue rates are biggest difference btw high and low performing centers

pubmed.ncbi.nlm.nih.gov/17893278/

#pedsICU #pedsCICU #CHD

@BostonChildrens @pc4quality #pedsCICU arrest rates vary ++ between centers & ++ btw highest / lowest risk pts

Hi risk pts – single v, HLHS, poor func, valve regurg

@PC4quality shows centers can learn collaboratively & reduce arrest rates 1/3 in a year

bit.ly/35LCsHd

#pedscards #pedsICU #CHD

@BostonChildrens @pc4quality Shared mental model of who the high risk pts are is essential

Ideally includes all staff: med, nursing etc, snr & jnr, surg, anesthesia, #pedsCICU and starts before the pt is in the OR

- of course this is not always so & we can do better

#pedscards #pedsICU #CHD #pedsICU

@BostonChildrens @pc4quality When single ventricle pts are not doing well, not doing well often starts in the operating room

#pedscards #pedsICU #CHD #pedsICU

@BostonChildrens @pc4quality Opportunities to identify risk in #pedsICU & #pedsICU by physiology – @etiometry, vital signs warning scores

Opportunities to communicate risk: rounds, sign out

#pedscards #CHD

@BostonChildrens @pc4quality @etiometry Be precise about pathophysiology affecting pts at every point

Otherwise well intentioned tx can harm – e.g restrictive RV + ASD may be desaturated but w good cardiac output. Trying to ‘normalise’ ventilation may ➡ low CO

#pedscards #pedsICU #CHD #pedsICU

@BostonChildrens @pc4quality @etiometry Seniors in the #pedsICU should be precise about limits and parameters requiring further discussion, esp. w sick pts e.g. “epi above 0.05, loop me back in”

#pedscards #pedsCICU #CHD

@BostonChildrens @pc4quality @etiometry In very big #pedsCICU & #pedsICU units it is hard to be aware of and manage risk

We often talk about units being too small but is there also an upper limit and are some of the big units approaching this?

#pedscards #CHD

@BostonChildrens @pc4quality @etiometry Q: Peri arrest single V pt– what is Ravi Thiagarajan doing in first 10s?

A: Glance at monitor, airway patent? bilat breath sounds, assess circ, low dose epi + consider pt specifics

ID reversible causes & consider #ECMO to support PRE arrest

#pedscards #pedsCICU #CHD #pedsICU

@BostonChildrens @pc4quality @etiometry CPR is inefficient even in pts with normal circulation – more so in single V

Chance of ROSC in single v is low – mobilise ECPR early

Even if get ROSC may still benefit from period of #ECMO support to prevent ongoing organ injury & 2nd arrest.

#pedscards #pedsCICU #CHD #pedsICU

@BostonChildrens @pc4quality @etiometry Invasive monitoring can allow optimization of CPR in #pedsICU

Arterial line waveform probably best but etCO2, SpO2 & NIRS may all be helpful

#pedscards #pedsCICU #CHD

@BostonChildrens @pc4quality @etiometry Good CPR during ECPR initiation is ++ challenging

Compressions too fast: ⬇ heart filling

+ interruptions & variable quality internal massage during cannulation

Address in training. During event avoid task fixation & keep team informed

#pedscards #pedsCICU #CHD #pedsICU

@BostonChildrens @pc4quality @etiometry For cardiac arrest in fresh post op #pedsCICU patient focus on chest compressions & re-opening chest

Chest opening addresses both fluid & tissue tamponade

Done by #pedsICU team or surgeons depending on center

#pedscards #CHD

@BostonChildrens @pc4quality @etiometry Pts who get rapid ROSC:

Clearly reversible cause – somewhat reassuring

No clear cause - #ECMO team should stick around for 30 min to monitor circulation

ROSC but high vasoactive doses / rising lactate – benefit from ECMO support

#pedscards #pedsCICU #CHD #pedsICU

@BostonChildrens @pc4quality @etiometry Potentially reversible causes (+ treatments) of arrest in post op #pedsCICU

Arrhythmia (meds, change wires), tamponade (open chest, re-explore)

But...reversible issues are often symptoms of underlying fragility & semi-elective ECMO may avoid 2nd arrest

#pedscards #CHD #pedsICU