The slide above is from an SCCM talk by Robert Sutton. Dr. Sutton is a pediatric intensivist at CHOP in Philadelphia. His research interests include pediatric CPR quality research with a focus on evaluating novel interventions, both educational and technological, with the overall goal to improve care delivered to children during resuscitation attempts.
What We Spoke About…
We went box by box through the algorithm above. Note, very little of this is supported by high level evidence. However, neither is anything we are doing now–so be wary of staus quo bias.
Additional Info
- An article by Dr. Sutton on Hemodynamic Guided CPR
- Physio-Guided CPR1
- Article: Ahn, S et al. Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study. J Thorac Dis 2018; 104(4): 2295-2302
from rebelem - Comp. of DBP and ETCO2 for CT quality (hint DBP is better)
- Brain Ox
Note: To do this technique properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.
Prior Posts on EMCrit
Now on to the Podcast…
1.
Morgan RW, Sutton RM, Berg RA. The Future of Resuscitation. Pediatric Critical Care Medicine. 2017;18(11):1084-1086. doi:10.1097/pcc.0000000000001316
Additional New Information
More on EMCrit
- EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest(Opens in a new browser tab)
- Podcast 191 – Cardiac Arrest Update(Opens in a new browser tab)
- EMCrit 244 – Incredibly Important Wrinkles to Titrated Vasopressors during CPR in Cardiac Arrest with PO Berve(Opens in a new browser tab)
Additional Resources
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Wow, just in time for a cardiac arrest/code talk I’m about to give the residents. It’s overwhelming to visualize discussing the “novel interventions,” but I’m reassured by the fact that very little is of “high-quality” evidence. Thank you, all.
thank you, scott and dr sutton. very detailed, very illuminating,
tom
What about Phenylephrine in cardiac arrest? Pure alpha stimulation seems to be a good idea. Haven’t done an extensive search on it, but there seems to be at least some (old) evidence that it had similar outcomes to adrenalin. Especially in cases with the ‘intractable vasoplegia’ that you talk about.
only hits alpha-1. ostensibly this is problematic, though it is beyond me if this is true or not
Hitting only alpha-1 seems interesting but it can produce bradycardia (not necessarily a problem if already puseless) and increase afterload, via augmenting systemic vascular resistance (SVR), without a little bit of B1 that can possibly compensate that effect. This might give suboptimal condition for ROSC.
An interesting alternative might be norepinephrine (alpha-1 with a little bit of B1) based on the receptor. Not really evidence behind this. Have found only this case report with a quick search ; https://www.ncbi.nlm.nih.gov/pubmed/24997106. This could be interesting to check this in a futur study.
thanks Scott, enjoyed the show as always!
norepi is what I use. We actually keep a basal infusion of 50 mcg/min running throughout the code. I think the bolus should be norepi and vaso to get DBP >40.
2 questions Scott:
1- just so I’m clear on this, you don’t use epi in cardiac arrest – only norepi?
2- why not pure alpha agonism?
Thanks!
nope you misunderstood
run norepi infusion in the background, give epi to get DBP up
pure alpha would be great. phenyl doesn’t do it–it only hits one of the alpha receptors.
LaTeral approach ultrasound looking at the transhepatic IVC. Watch venous wire go up…
Re: identification of vessels
Is there a quick way of, without causing clinically significant delays, applying intravascular ultrasound similar to within coronaries to compare wall thickness as a means of confirmation of artery Vs vein? Might it be more reliable than linear/curvilinear probe to skin?
Suggesting as a definite non-expert.
Enjoyed the show as always!
wow, I’ve only heard about these, never saw one. Do you have access to one What size catheters will they fit in
No personal experience with them. Had a quick look and late 90s/early 00s was some work on using it to help size AAA stents and comparing the accuracy with CT. Seems to suggest reliable judgement of wall thickness given a very brief glance over.
Unable to speak to the practicality or usefulness of adding it into an already complex procedure like ECMO for vessel confirmation.
wrt access in arrest, ‘which vessel am I in?’
-as a quite junior registrar I once did a femoral cutdown on a high BMI arrest that we had no access on, pre-days of IO being the go to access.
Just putting it out there……
The rest does seem like science fiction and not entirely transferable to normal practice. even in 10years…..But Fascinating,
What are the setting/ breakdown of the paeds arrests being discussed here? In hospital? Trauma? Maybe I missed the spiel…….
so that makes my shop, Sharp in San Diego, my old place in NYC like a sci-fi novel–super cool!
In re: cutdown
the larger the patient, the less desirous a cutdown becomes. thankfully fat, transmits ultrasound beautifully if adequate pannus retraction
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263031/
No reason this shouldn’t work if you look at the ivc with fem access. You may need an aggitated bolus larger than 10 ml to make sure it gets there if the patient doesn’t have a pulse though.
Seems the simplest thing would to put a small catheter over the guidewire you assume is the vein (like the ones in the central line kits on the slip tip needle), inject agitated saline and watch the vein light up right there (with the linear probe in the groin).
Seems the simplest thing would to put a small catheter over the guidewire you assume is the vein (like the ones in the central line kits on the slip tip needle), inject agitated saline and watch the vein light up right there (with the linear probe in the groin).
For identification/differentiation of the vessels, assuming you can’t see the differences in wall thickness on ultrasound, (and I’m spitballing here) what about using anatomy distal to the insertion site to differentiate them? e.g. saphenous take off. Also, it was great to hear this on EMCrit! I remember picking Dr. Sutton’s brain on hemodynamic guided resus and his general takes on pediatric resus during my PICU rotation with the 10006/admit/code team fellow at CHOP. Subsequent attempts to bring this up among adult crit care folks is not always met with more than funny looks. I hope we get some more data… Read more »
Sorry for the late comment … just getting caught up on podcasts. We’re working on developing goal-directed resuscitation at our facility and I was wondering if anyone knows of any registries that have comprehensive datasets looking at in-hospital cardiac arrest, similar to CARES or GWTG-R for OHCA. We participate with INTCAR, but we’re only abstracting on patients that get cooled, which means we’re not investigating a lot of the CA population.
If epinephrine is given to increase diastolic pressure and perfuse the coronaries during arrest, and too much beta-agonism is thought to precipitate arrhythmias, why note use a pure alpha agonist like phenylephrine during resuscitations?