Papers by Semestre 6 Gupo C FUAM
Many key issues in the review of the pediatric advanced life support literature resulted in refin... more Many key issues in the review of the pediatric advanced life support literature resulted in refinement of existing recommendations rather than in new recommendations. New information or updates are provided about fluid resuscitation in febrile illness, atropine use before tracheal intubation, use of amiodarone and lidocaine in shock-refractory VF/pVT, TTM after resuscitation from cardiac arrest in infants and children, and post–cardiac arrest management of blood pressure. In specific settings, when treating pediatric patients with febrile illnesses, the use of restrictive volumes of isotonic crystalloid leads to improved survival. This contrasts with traditional thinking that routine aggressive volume resuscitation is beneficial. Routine use of atropine as a premedication for emergency tracheal intubation in non-neonates, specifically to prevent arrhythmias, is controversial. Also, there are data to suggest that there is no minimum dose required for atropine for this indication. If invasive arterial blood pressure monitoring is already in place, it may be used to adjust CPR to achieve specific blood pressure targets for children in cardiac arrest. Amiodarone or lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF and pVT in children. Epinephrine continues to be recommended as a vasopressor in pediatric cardiac arrest. For pediatric patients with cardiac diagnoses and IHCA in settings with existing extracorporeal membrane oxygenation protocols, ECPR may be considered. Fever should be avoided when caring for comatose children with ROSC after OHCA. A large randomized trial of therapeutic hypothermia for children with OHCA showed no difference in outcomes whether a period of moderate therapeutic hypothermia (with temperature maintained at 32°C to 34°C) or the strict maintenance of normothermia (with temperature maintained 36°C to 37.5°C) was provided. Several intra-arrest and post–cardiac arrest clinical variables were examined for prognostic significance. No single variable was identified to be sufficiently reliable to predict outcomes. Therefore, caretakers should consider multiple factors in trying to predict outcomes during cardiac arrest and in the post-ROSC setting. After ROSC, fluids and vasoactive infusions should be used to maintain a systolic blood pressure above the fifth percentile for age. After ROSC, normoxemia should be targeted. When the necessary equipment is available, oxygen administration should be weaned to target an oxyhemoglobin saturation of 94% to 99%. Hypoxemia should be strictly avoided. Ideally, oxygen should be titrated to a value appropriate to the specific patient condition. Likewise, after ROSC, the child's Paco should be targeted to a level appropriate to each patient's condition. Exposure to severe hypercapnia or hypocapnia should be avoided. 2 Recommendations for Fluid Resuscitation 2015 (New): Early, rapid IV administration of isotonic fluids is widely accepted as a cornerstone of therapy for septic shock. Recently, a large randomized controlled trial of fluid resuscitation conducted in children with severe febrile illnesses in a resource-limited setting found worse outcomes to be associated with IV fluid boluses. For children in shock, an initial fluid bolus of 20 mL/kg is reasonable. However, for children with febrile illness in settings with limited access to critical care resources (ie, mechanical ventilation and inotropic support), administration of bolus IV fluids should be undertaken with extreme caution, as it may be harmful. Individualized
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Papers by Semestre 6 Gupo C FUAM