Introduction:
The American Heart Administration recommends against spoon-feeding IV (intravenous) calcium during CPR (cardiopulmonary resuscitation) for children who have suffered in-hospital cardiac arrest (IHCA) since it has been related to worse survival and should only be utilized in certain circumstances (AHA). The 4,556 kids who had an IHCA and had pre-existing heart disease were included in this multicenter, retrospective cohort study. With the aid of propensity score matching, the primary outcome of survival to discharge from the hospital was compared between children who were administered calcium during CPR against those who did not.
In 1,986 (44 percent) of the patients, calcium was given, and it was typically given during extended durations of CPR. Even after adjusting for CPR duration, age, metabolic or electrolyte disturbances, and illness category, it was still linked to a lower survival to hospital discharge. Although this was a study, it might not be highly applicable to the majority of the patients seen in the emergency room (IHCA patients were excluded). The AHA guidelines, which now advise against routine intravenous infusion of calcium administration during pediatric cardiac arrest, and earlier studies evaluating calcium for IHCA, however, lead to believe that IV calcium during CPR should be avoided unless there is a very good reason. This paper focuses on pediatric cardiac arrest, CPR, and therapeutic interventions that impact clinical outcomes.
What Are the Factors Involved in Calcium Administration?
There are other crucial factors to take into account, even though this emphasis is also advised for infants and kids with heart disease. Three factors specific to this particular population make this scientific statement significant:
1. Infants and children with congenital heart disease (CHD) are more likely to experience cardiac arrest, and the pathogenesis of these events can be different from that of infants and children without heart disease.
2. Congenital heart defects have a wide range of hemodynamic and physiological influences on cardiac output, and the specific cardiorespiratory interactions and response to resuscitation can be quite variable.
3. The response of the neonate and the postoperative period is quite variable.
How Is Calcium Administered During CPR in Children With Heart Disease?
Cardiopulmonary resuscitation (CPR) has four distinct phases: pre-arrest, no flow (untreated cardiac arrest), low flow (CPR), and post-arrest. Respiratory insufficiency is the most frequent precipitating factor for cardiac arrest in children. Therefore, restoring adequate ventilation and oxygenation is still a top priority. High-quality CPR improves the outcomes of cardiac arrest (for example, pushing hard, pushing quickly, permitting full chest recoil, and minimizing interruptions in chest compressions). Reflective debriefings of team performance, along with real-time monitoring and feedback, enhance CPR effectiveness and survival rates. Careful post-resuscitation attention should be given. Specifically, avoiding hypotension and fever improves survival rates. A promising method to save more children from cardiac arrest is physiology-detected CPR, which titrates CPR to a patient’s physiological response.
Pediatric cardiac arrest is not a rare event. More than 20,000 children are treated with cardiopulmonary resuscitation (CPR) for cardiac arrest in the United States annually. In the past, survival outcomes were dismal, and many surviving children had severe neurologic sequelae. With advances in resuscitation science, survival from pediatric cardiac arrest has improved substantially since the 1990s.
Pre-arrest Phase:
The term prearrest phase refers to the child’s relevant preexisting conditions (such as neurologic disability, pulmonary hypertension, sepsis, and respiratory insufficiency or failure), as well as the circumstances that led to cardiac arrest (for example, respiratory decompression, progressive hypotension and shock, pulmonary hypertensive crisis, drug overdose). Interventions during the prearrest phase should concentrate on identifying children at risk for arrest, with special attention to early recognition and treatment of respiratory failure and shock. This is because pediatric patients typically show variations in their physiologic status in the hours prior to their arrest event. In hospitals, emergency teams specifically created for this activity are called rapid response teams or medical emergency teams. These teams now exist in almost all pediatric institutions, despite the fact that their makeup and working methods differ greatly.
No Flow and Low Flow Phase:
It is crucial to reduce the no-flow phase of untreated cardiac arrest in children in order to improve outcomes. In order to facilitate early detection of cardiac arrest and to start basic and advanced life support, it is important to manage high-risk patients. Effective CPR maximizes cardiac output and coronary perfusion pressure to support the survival of vital organs during the low-flow phase. The following basic life support principles are crucial,
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Push hard.
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Push fast.
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Allow full chest recoil between compressions.
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Minimize chest compression interruptions.
Successful resuscitations for ventricular fibrillation and pulseless ventricular tachycardia depend on quick rhythm identification and prompt defibrillation. It is crucial to restoring myocardial oxygenation and adequate myocardial perfusion for all cardiac arrests.
Post-arrest Phase:
The majority of pediatric CPR patients’ deaths happen after initial effective resuscitation. As a result, the period right after an arrest should be treated as an important time for ongoing treatment. Patients continue to be at risk for serious organ reperfusion injuries and ventricular arrhythmia. The goal of interventions in the immediate post-arrest period should be to reduce secondary injury. Current evidence-based objectives include the following.
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Prevent hypotension (systolic blood pressure below the fifth percentile for age).
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Prevent fever by actively managing temperature.
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Identity and treat seizures.
The most innovative developments to enhance the functional status and ease the patient’s reintegration back into society may occur during this post-arrest phase. The focus of care is determined by the particular stage of resuscitation. Interventions that boost performance during one stage might have negative effects during another. To increase coronary perfusion pressure and the likelihood of event survival, vasopressors are given during the low-flow phase of cardiac arrest, which increases systemic vascular resistance. This vasoconstriction may worsen myocardial strain and dysfunction and have a negative effect on cerebral perfusion if it persists into the post-arrest phase.
Conclusion:
There is a lot of hope that critical care interventions will pave the way to more effective cardiopulmonary and cerebral resuscitation in children by strategically focusing therapies on particular stages of cardiac arrest. These advancements may be attributable to the growing fields of pediatric critical care and pediatric emergency medicine as well as our growing understanding of the pathophysiologic events that occur during and after pediatric cardiac arrest. Additionally, exciting developments in basic and applied science laboratories, like physiologically directed CPR, are soon to be put into practice. Future techniques will probably benefit from a growing understanding of cellular metabolism, mitochondrial bioenergetics, cellular metabolism, and cellular markers of injury and recovery.
