Resuscitation

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It’s Finally Here: New AHA Statement On Resuscitation In Pediatric Patients With Heart Disease And Comments From The Author

David Werho, MD

Do you want to read something amazing, awesome, and interesting? The AHA recently published its latest Scientific Statement: Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease. 

Cardiac arrest in the hospital is 10 times more common among children with congenital heart defects or other acquired heart conditions compared to children with healthy hearts, according to the statement published Monday in the journal Circulation.  As a pediatric cardiac intensivist, I often find myself overthinking things when I go for my PALS or ACLS recertification.  “Well, if the patient is having a pulmonary hypertensive crisis, then I’d actually do this also…” or “At this point, I would have already activated ECMO.” In all honesty, I don’t reach for my PALS card during a real-life resuscitation in the pediatric cardiac ICU anymore.  Not because I don’t follow the guidelines – I am the first to admit that high-quality CPR is the cornerstone of resuscitation and my team has these algorithms streamlined and burned into the backs of our minds – but because I have so many other things going through my head for this patient population.  (Does this baby have pacing wires? What vessels are patent? Is the shunt occluded? How will vasopressin affect this kid’s physiology? Has this chest tube been draining appropriately leading up to the arrest?)  None of these things are specifically addressed in the AHA resuscitation guidelines, until now. 

Bradley S. Marino, MD, MPP, MSCE, Professor of Pediatrics and Medical Social Sciences at the Northwestern University Feinberg School of Medicine and a Pediatric Cardiac Intensivist at Ann & Robert H. Lurie Children’s Hospital and Chair of the AHA Council on Cardiovascular Disease in the Young along with his expert colleagues on the AHA Congenital Cardiac Defects Committee have painstakingly taken the time to address the unique issues surrounding peri-resuscitation care and considerations for the high-risk pediatric cardiac population.  “The new statement is meant to be a powerful tool for health care professionals to both improve survival in children with heart disease who have a cardiac arrest and prevent cardiac arrests from ever happening in these high-risk children,” said Dr. Marino.  “This scientific statement is a critical supplement to the American Heart Association’s Pediatric Advanced Life Support Guidelines that has been long overdue,” Marino said.

I asked Dr. Marino what the most important thing was that the authors learned while putting together the statement. “Given the incidence of cardiac arrest in the pediatric cardiac population, activities to prevent cardiac arrest are very important.  We need to do more to modify our present clinical care systems to minimize the incidence of cardiac arrest.  In addition, we need to tailor our resuscitation strategies for children with cardiac disease. While the PALS recommendations are very helpful to resuscitate all children with cardiac arrest, more information was needed to address the special needs of the pediatric cardiac population.”

The statement reviews all of the stages of cardiopulmonary resuscitation (pre-arrest, during CPR, and post-resuscitation care) and the considerations for each stage of single-ventricle palliation, right- and left-sided heart disease, pulmonary hypertension, cardiomyopathies and myocarditis, and arrhythmias.  They also speak to considerations related to patient age, patient location, ECPR, and all of the various pharmacologic agents that we use frequently in these patients. 

As for Dr. Marino’s hopes for providers to take away after reading the statement, he says “Tailoring resuscitation is possible once providers understand the specific anatomy, physiology, and cardiopulmonary interaction that is present at each patient’s bedside.”

It’s definitely a long document to read through, but is a critical review for all providers who care for pediatric patients with heart disease, especially those of us in the ICU setting.  Click here to read it.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.
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Paradigm Shifts In Resuscitation

David Werho, MD

We go through a series of paradigm shifts during our childhood and development: the moments that change our outlook on the world around us and how we influence it.

  • “There’s a whole world outside of my home!”
  • “People can be really cruel!”
  • “Sharing is caring.”
  • “Chicken pox are contagious!”

Similar shifts occur in our development as physicians. I remember very distinctly the moment that the pathophysiology of heart failure finally just “clicked” in my mind.

A similar shift occurred as I reviewed a recent AHA news brief on survival in out-of-hospital cardiac arrest. Unconsciously, I had developed a thought-process around out-of-hospital cardiac arrest that was very skewed.

  • As a child, I thought of CPR as some sort of strange voodoo magic that only lifeguards and doctors could perform. It always worked and brought people back to life immediately with nothing but a residual cough (as they spit out water and seaweed, usually).
  • Then, as I trained to become a BLS instructor during medical school, I realized that anyone could do CPR, but it didn’t always work. There was no magic about it – it was pure science.
  • Through my years in medical school, residency, cardiology fellowship, and critical care fellowship, I saw patients who never recovered, or who had profoundly poor outcomes despite survival and I began to think of out-of-hospital cardiac arrest as sort of hopeless. Of course, there was the occasional patient who walked out of the ICU, but I felt like most of the time, if CPR was done outside the hospital, it was not going to end well.

However, after reading about the profound increase in survival and improved functional outcomes after bystanders used AEDs for patients with out-of-hospital cardiac arrest, I suddenly have much more hope. I look back on my own experiences and realize that those patients who did well were the ones who had immediate bystander CPR /- the AED, depending on the etiology of arrest. I think my learned pessimism made it more difficult for me to recognize this connection. But, studies like this show that the evolution in resuscitation science, public health and safety culture, and education can make huge differences in our world. It makes me more hopeful for the future and more thoughtful about ways that I can influence the health and safety of those around me. I think I’m more hopeful now that even small efforts towards improved public health, not just around resuscitation, but anything that makes a positive impact, are worthwhile.

David Werho Headshot

David K. Werho, MD is an Assistant Clinical Professor at the University of California San Diego and a Pediatric Cardiac Intensivist at Rady Children’s Hospital – San Diego.  His research focuses on pediatric cardiac ICU outcomes as well as interventions and curriculum development in medical education.  He tweets @DWerho and contributes to the Pediatric Cardiac Intensive Care Society Newsletter as editor and contributor.