- Email: [email protected]
Vasopressin in refractory paediatric cardiac arrests—A case series
S60
Abstracts / Resuscitation 81S (2010) S1–S114
AP102 Endotracheal intubation at the emergency department Haugk M., Stratil P., Sterz F., Krizanac D., Testori C., Uray T., Hoerburger D., Schober A., Wallmueller C., Stoeckl M., Schreiber W. Emergency Department, General Hospital Vienna,Medical University Vienna, Austria Purpose of the study: To evaluate the frequency and difficulties of endotracheal intubation at the Emergency Department of the General Hospital Vienna. Materials and methods: Staff physicians of our department filled out a specially designed detailed questionnaire after performing an endotracheal intubation. The questions included demographic data, the indication for intubation (semi-elective, emergency, tube exchange), attempts until confirmed proper tube placement and difficulties during performance including alternatives for difficult airway management. Descriptive statistics were used to analyse the data. Results: From 10/2005 to 06/2010 a total of 530 questionnaires were returned. From these 530 patients, 231 (44%) were female. Mean age was 59 ± 17 years. 199 (38%) intubations were classified as emergency intubations, 258 (49%) as semielective intubations, and 73 (13%) as tube-exchanges. 127 (24%) patients were intubated because of cardiopulmonary resuscitation, 223 (42%) due to respiratory failure, 63 (12%) because of intracranial hemorrhage, and 41 (8%) because of intoxication. 506 (95%) conventional orotracheal intubations were performed. Proper tube placement was confirmed in 382 (75%) patients after the first attempt, in 89 (18%) patients after the second attempt, in 22 (4%) patients after the third attempt and in 13 (2.6%) patients after 4 or more attempts. In 24 (5%) patients, alternative airway management procedures such as endoscopic intubation or the utilisation of a Combitube or LMA-Fastrach had to be performed. Our data underestimate the overall frequency of intubations at our department because an uncertain number of intubations were not documented due to several reasons (e.g. questionnaires were not filled out or were not returned to the investigators). Conclusion: Airway management at our emergency department is not a daily, but no rare event. On average, every third day a patient has to be intubated under emergency conditions by our staff. Therefore, personnel must be well trained in airway management. doi:10.1016/j.resuscitation.2010.09.247 AP103 Learning curve for orotracheal intubation for nurse anesthetist trainees Pulnitiporn A., Nontaphan K., Pomsuwan W., Sangsawang J., Supharoekmongkhon C. Department of Anesthesiology, KhonKaen Hospital, KhonKaen, Thailand Purpose of the study: To determine numbers of orotracheal intubation needed for nurse anaesthetist trainees to attain acceptable success rate. Materials and methods: Prospective observational study was conducted during November 2009 through March 2010. Data on orotracheal intubations performed by 13 nurse anaesthetist trainees were collected. None of the participants had experience in orotracheal intubation before the study. After 2 h lecture and at least 20 times practice on manikins, trainees were allowed to perform orotracheal intubation under supervision of attending anaesthesiologists. Expected difficult intubation was excluded from the study. Learning curve was calculated by using the mean success rate and 95% confidence interval. Results: 1227 orotracheal intubations were included with overall success rate 89.1%. The average cases per trainee were 94.3 (95% CI: 90.4–98.3). The success rate reached 80% and 85% after a mean of 22 and 39 attempts, respectively. However success rates of two trainees were less than 80% even after 55 attempts. All of trainees attained 80% success rate at 85 attempts. Conclusions: By using learning curve, allow us to determine minimum number of orotracheal intubation required for nurse anaesthetist training program to ensure proficiency of the trainee. doi:10.1016/j.resuscitation.2010.09.248
Drugs AP104
to provide a comparison with other published reports. Reviewing our four cases, that all occurred in patients who had either primary cardiac causes for arrest or underlying cardiac conditions. All had ROSC (100%), three survived to hospital discharge (75%) and these three had a good neurological outcome (75%). This compares favourably with other data on AVP and Terlipressin use in paediatric cardiac arrest published since the 2005 ILCOR paediatric guidelines. We believe that our cases add to the literature and suggests that vasopressin may be useful in paediatric cardiac arrest due to cardiac causes rather than in cases of prolonged hypoxia. doi:10.1016/j.resuscitation.2010.09.249
Mechanical Devices AP105 Case-report: “European medical assisted transfer of a patient with refractory cardiogenic shock supported by extracorporal membrane oxygenation to tertiary care center, a challenge for the future in patient transport?” Beissel J. 1 , Clarens C. 2 , Feiereisen P. 3 , Risch A. 3 , Thiranos J.C. 4 , Mazzucotelli J.P.H. 5 1 Department
of Cardiology, Hospital Center, Luxembourg, GDL Emergency Medical Service, Fire-Brigade, Luxembourg, GDL Department of Anaesthetics, National Institute of Cardiac Surgery, Luxembourg, GDL 4 Department of Anaesthetics, Regional University Hospital Center, Strasbourg, France 5 Department of Cardio-Surgery, Regional University Hospital Center, Strasbourg, France 2 3
Purpose of study: European Medical Assisted Transport on May 15th 2010 of postresuscitation cardiac patient in cardiogenic shock, supported by ExtraCorporal Membrane Oxygenator (ECMO) and Intra-Aortic Balloon Pump (IABP) from NICS to the Tertiary Care RUHC in Strasbourg raised our interest in out-of-hospital Mobile Unit of Cardiac Assistance (MUCA).1 Main goal: Assess feasibility of MUCA transport facilities for critical hemodynamic patients in Luxembourg.2 Materials and methods: Review of medical literature,3 related data collected during transport and interviews of implicated staff from concerned hospitals gave us necessary patient-related information about progression of refractory cardiac failure and applied treatment. Results: Medical history: 47-year-old man – first inferior ischemic cardiomyopathic process in 2005 – during second hospital stay starting May 9th 2010: progression of cardiogenic shock with pulmonary edema, reversed ventricular fibrillations – transfer to NICS – diagnosis of severe coronary disease and performance of Percutaneous Coronary Intervention (PCI) and IABP – episodes of ventricular fibrillation with hemodynamic instability and poor left ventricular ejection fraction (20%)-implantation of ECMO and decision to transfer to RUHC for implantation of Left Ventricular Assist Device (VAD) and/or heart transplantation. Despite of difficult circumstances, patient arrived in stable conditions. In Intensive Heart Surgery Care Unit of RUHC, no neurological abnormalities were detected. Renal and hepatic failures were treated with hemodialysis. After 14 days, left ventricular ejection fraction was still beneath 20%. Due to unsuccessful weaning from ECMO, biventricular assist device was implanted. After treatment of septic shock, patient was weaned from ventilation at day 24. Unfortunately, a fatal cerebral hemorrhage occurred 57 days after transfer. Conclusion: This case report underlines the benefits of a well organised MUCA for critical patients in severe cardiogenic shock with refractory cardiac failure.4,5 European collaboration helped patient and staff in staying hopeful. References 1. Pavie A, Leprince P, Bonnet N, Barreda T, Gandjbakhch I. Interest of the mobile unit of cardiac assistance (MUCA) in critical hemodynamic circumstances. e-Memories of the National Academy of Surgery 2006;5:56–63. 2. Bieniek V. Patient Transport with ECMO: SAMU 38. La revue des SAMU –Médecine d’Urgence 2009; 451–2. 3. Haft JW, Pagani DF, Romano AM, Leventhal LCh, Dyke BD, Matthews CJ. Short and Long Term Survival of Patients transferred to a Tertiary Care Center on Temporary Extracorporeal Circulatory Support. Ann Thorac Surg 2009;88:711–8. 4. Vanzetto G, Akret Ch, Bach V, et al. Percutaneous Extracorporeal Circulatory Assistance in acute hemodynamic failure: a monocentric expérience of 100 patients. Can J Cardiol 2009;25, e179–e186. 5. Riou B, Adnet F, Baud F, et al. Guidelines for indications of circulatory assistance in treatment of refractory cardiac arrests. La revue des SAMU – Médecine d’Urgence 2008: 439–42.
Vasopressin in refractory paediatric cardiac arrests—A case series Alexander G., Dean S., White M. Resuscitation Services, University Hospitals Bristol, NHS Foundation Trust, United Kingdom The published evidence for use of Arginine AVP or its synthetic analog Terlipressin (TP) in paediatric cardiac arrest is very limited. Vasopressin has many therapeutic uses in adults and children but the benefit in paediatric cardiac arrest is unclear. Paediatric cardiac arrest is uncommon, unpredictable and clearly life threatening. This makes undertaking an in vivo randomised controlled clinical trial both practically and ethically challenging. Therefore, in the absence of a large multicentre trial, evidence for/against the use of vasopressin is likely to come from retrospective case series, isolated case reports and animal data. Following a review of the literature we decided, at the discretion of the attending paediatric intensive care consultant, to use vasopressin in prolonged paediatric cardiac arrest. As part of our clinical governance we have audited our practice and present our findings. The use of AVP is described in a series of 4 case studies and the data analysed
doi:10.1016/j.resuscitation.2010.09.250
Abstracts / Resuscitation 81S (2010) S1–S114
AP102 Endotracheal intubation at the emergency department Haugk M., Stratil P., Sterz F., Krizanac D., Testori C., Uray T., Hoerburger D., Schober A., Wallmueller C., Stoeckl M., Schreiber W. Emergency Department, General Hospital Vienna,Medical University Vienna, Austria Purpose of the study: To evaluate the frequency and difficulties of endotracheal intubation at the Emergency Department of the General Hospital Vienna. Materials and methods: Staff physicians of our department filled out a specially designed detailed questionnaire after performing an endotracheal intubation. The questions included demographic data, the indication for intubation (semi-elective, emergency, tube exchange), attempts until confirmed proper tube placement and difficulties during performance including alternatives for difficult airway management. Descriptive statistics were used to analyse the data. Results: From 10/2005 to 06/2010 a total of 530 questionnaires were returned. From these 530 patients, 231 (44%) were female. Mean age was 59 ± 17 years. 199 (38%) intubations were classified as emergency intubations, 258 (49%) as semielective intubations, and 73 (13%) as tube-exchanges. 127 (24%) patients were intubated because of cardiopulmonary resuscitation, 223 (42%) due to respiratory failure, 63 (12%) because of intracranial hemorrhage, and 41 (8%) because of intoxication. 506 (95%) conventional orotracheal intubations were performed. Proper tube placement was confirmed in 382 (75%) patients after the first attempt, in 89 (18%) patients after the second attempt, in 22 (4%) patients after the third attempt and in 13 (2.6%) patients after 4 or more attempts. In 24 (5%) patients, alternative airway management procedures such as endoscopic intubation or the utilisation of a Combitube or LMA-Fastrach had to be performed. Our data underestimate the overall frequency of intubations at our department because an uncertain number of intubations were not documented due to several reasons (e.g. questionnaires were not filled out or were not returned to the investigators). Conclusion: Airway management at our emergency department is not a daily, but no rare event. On average, every third day a patient has to be intubated under emergency conditions by our staff. Therefore, personnel must be well trained in airway management. doi:10.1016/j.resuscitation.2010.09.247 AP103 Learning curve for orotracheal intubation for nurse anesthetist trainees Pulnitiporn A., Nontaphan K., Pomsuwan W., Sangsawang J., Supharoekmongkhon C. Department of Anesthesiology, KhonKaen Hospital, KhonKaen, Thailand Purpose of the study: To determine numbers of orotracheal intubation needed for nurse anaesthetist trainees to attain acceptable success rate. Materials and methods: Prospective observational study was conducted during November 2009 through March 2010. Data on orotracheal intubations performed by 13 nurse anaesthetist trainees were collected. None of the participants had experience in orotracheal intubation before the study. After 2 h lecture and at least 20 times practice on manikins, trainees were allowed to perform orotracheal intubation under supervision of attending anaesthesiologists. Expected difficult intubation was excluded from the study. Learning curve was calculated by using the mean success rate and 95% confidence interval. Results: 1227 orotracheal intubations were included with overall success rate 89.1%. The average cases per trainee were 94.3 (95% CI: 90.4–98.3). The success rate reached 80% and 85% after a mean of 22 and 39 attempts, respectively. However success rates of two trainees were less than 80% even after 55 attempts. All of trainees attained 80% success rate at 85 attempts. Conclusions: By using learning curve, allow us to determine minimum number of orotracheal intubation required for nurse anaesthetist training program to ensure proficiency of the trainee. doi:10.1016/j.resuscitation.2010.09.248
Drugs AP104
to provide a comparison with other published reports. Reviewing our four cases, that all occurred in patients who had either primary cardiac causes for arrest or underlying cardiac conditions. All had ROSC (100%), three survived to hospital discharge (75%) and these three had a good neurological outcome (75%). This compares favourably with other data on AVP and Terlipressin use in paediatric cardiac arrest published since the 2005 ILCOR paediatric guidelines. We believe that our cases add to the literature and suggests that vasopressin may be useful in paediatric cardiac arrest due to cardiac causes rather than in cases of prolonged hypoxia. doi:10.1016/j.resuscitation.2010.09.249
Mechanical Devices AP105 Case-report: “European medical assisted transfer of a patient with refractory cardiogenic shock supported by extracorporal membrane oxygenation to tertiary care center, a challenge for the future in patient transport?” Beissel J. 1 , Clarens C. 2 , Feiereisen P. 3 , Risch A. 3 , Thiranos J.C. 4 , Mazzucotelli J.P.H. 5 1 Department
of Cardiology, Hospital Center, Luxembourg, GDL Emergency Medical Service, Fire-Brigade, Luxembourg, GDL Department of Anaesthetics, National Institute of Cardiac Surgery, Luxembourg, GDL 4 Department of Anaesthetics, Regional University Hospital Center, Strasbourg, France 5 Department of Cardio-Surgery, Regional University Hospital Center, Strasbourg, France 2 3
Purpose of study: European Medical Assisted Transport on May 15th 2010 of postresuscitation cardiac patient in cardiogenic shock, supported by ExtraCorporal Membrane Oxygenator (ECMO) and Intra-Aortic Balloon Pump (IABP) from NICS to the Tertiary Care RUHC in Strasbourg raised our interest in out-of-hospital Mobile Unit of Cardiac Assistance (MUCA).1 Main goal: Assess feasibility of MUCA transport facilities for critical hemodynamic patients in Luxembourg.2 Materials and methods: Review of medical literature,3 related data collected during transport and interviews of implicated staff from concerned hospitals gave us necessary patient-related information about progression of refractory cardiac failure and applied treatment. Results: Medical history: 47-year-old man – first inferior ischemic cardiomyopathic process in 2005 – during second hospital stay starting May 9th 2010: progression of cardiogenic shock with pulmonary edema, reversed ventricular fibrillations – transfer to NICS – diagnosis of severe coronary disease and performance of Percutaneous Coronary Intervention (PCI) and IABP – episodes of ventricular fibrillation with hemodynamic instability and poor left ventricular ejection fraction (20%)-implantation of ECMO and decision to transfer to RUHC for implantation of Left Ventricular Assist Device (VAD) and/or heart transplantation. Despite of difficult circumstances, patient arrived in stable conditions. In Intensive Heart Surgery Care Unit of RUHC, no neurological abnormalities were detected. Renal and hepatic failures were treated with hemodialysis. After 14 days, left ventricular ejection fraction was still beneath 20%. Due to unsuccessful weaning from ECMO, biventricular assist device was implanted. After treatment of septic shock, patient was weaned from ventilation at day 24. Unfortunately, a fatal cerebral hemorrhage occurred 57 days after transfer. Conclusion: This case report underlines the benefits of a well organised MUCA for critical patients in severe cardiogenic shock with refractory cardiac failure.4,5 European collaboration helped patient and staff in staying hopeful. References 1. Pavie A, Leprince P, Bonnet N, Barreda T, Gandjbakhch I. Interest of the mobile unit of cardiac assistance (MUCA) in critical hemodynamic circumstances. e-Memories of the National Academy of Surgery 2006;5:56–63. 2. Bieniek V. Patient Transport with ECMO: SAMU 38. La revue des SAMU –Médecine d’Urgence 2009; 451–2. 3. Haft JW, Pagani DF, Romano AM, Leventhal LCh, Dyke BD, Matthews CJ. Short and Long Term Survival of Patients transferred to a Tertiary Care Center on Temporary Extracorporeal Circulatory Support. Ann Thorac Surg 2009;88:711–8. 4. Vanzetto G, Akret Ch, Bach V, et al. Percutaneous Extracorporeal Circulatory Assistance in acute hemodynamic failure: a monocentric expérience of 100 patients. Can J Cardiol 2009;25, e179–e186. 5. Riou B, Adnet F, Baud F, et al. Guidelines for indications of circulatory assistance in treatment of refractory cardiac arrests. La revue des SAMU – Médecine d’Urgence 2008: 439–42.
Vasopressin in refractory paediatric cardiac arrests—A case series Alexander G., Dean S., White M. Resuscitation Services, University Hospitals Bristol, NHS Foundation Trust, United Kingdom The published evidence for use of Arginine AVP or its synthetic analog Terlipressin (TP) in paediatric cardiac arrest is very limited. Vasopressin has many therapeutic uses in adults and children but the benefit in paediatric cardiac arrest is unclear. Paediatric cardiac arrest is uncommon, unpredictable and clearly life threatening. This makes undertaking an in vivo randomised controlled clinical trial both practically and ethically challenging. Therefore, in the absence of a large multicentre trial, evidence for/against the use of vasopressin is likely to come from retrospective case series, isolated case reports and animal data. Following a review of the literature we decided, at the discretion of the attending paediatric intensive care consultant, to use vasopressin in prolonged paediatric cardiac arrest. As part of our clinical governance we have audited our practice and present our findings. The use of AVP is described in a series of 4 case studies and the data analysed
doi:10.1016/j.resuscitation.2010.09.250