Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series

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1 Resuscitation 52 (2002) Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series Keith Mann a, Robert A. Berg b, Vinay Nadkarni c, * a Department of Pediatrics, Thomas Jefferson Uni ersity School of Medicine, A.I. dupont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19899, USA b Steele Memorial Children s Research Center, The Uni ersity of Arizona College of Medicine, 1501 N. Campbell A enue, P.O. Box , Tucson, AZ , USA c Department of Pediatrics, Thomas Jefferson School of Medicine, Department of Anesthesia and Critical Care, A.I. dupont Hospital for Children, P.O. Box 269, 1600 Rockland Road, Wilmington, DE 19899, USA Received 17 August 2001; received in revised form 31 August 2001; accepted 31 August 2001 Abstract Children who suffer cardiac arrest have a poor prognosis. Based on laboratory animal studies and clinical data in adults, vasopressin is an exciting new vasopressor treatment modality during cardiopulmonary resuscitation (CPR). In particular, vasopressin has resulted in short term resuscitation benefits as a rescue pressor agent in the setting of prolonged out-of-hospital CPR for ventricular fibrillation in adults. This retrospective series presents the first evidence for resuscitation benefit of bolus vasopressin therapy in the specific setting of pediatric cardiac arrest. All episodes of CPR initiated in a 120-bed tertiary care children s hospital over a three-year period ( ) were reviewed. Four children in the pediatric ICU received vasopressin boluses as rescue therapy during six cardiac arrest events, following failure of conventional CPR, advanced life support, and epinephrine vasopressor therapy. Return of spontaneous circulation for greater than 60 min occurred in three of four patients (75%) and in four of six CPR events (66%) following vasopressin administration. Two of four vasopressin recipients survived 24 h; one survived to hospital discharge and one had withdrawal of supportive therapies following family discussion. Our observations are AHA level 5 (retrospective case series) evidence that vasopressin administration may be beneficial during prolonged pediatric cardiac arrest. Such reports should pave the way for prospective clinical trials comparing vasopressor medications in the setting of pediatric cardiac arrest Elsevier Science Ireland Ltd. All rights reserved. Keywords: Vasopressin; Resuscitation; Cardiac arrest; Cardiopulmonary resuscitation (CPR); Children; Pediatric; Epinephrine; Vasopressor therapy 1. Introduction PII of linked article: S (01) * Corresponding author. Present address: Director, Pediatric Critical Care Fellowship Program, Department of Anesthesia and Critical Care, Children s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA Tel.: ; fax: address: nadkarni@ .chop.edu (V. Nadkarni). Children who suffer cardiac arrest have a poor prognosis, particularly when cardiac arrest is prolonged or refractory to more than two doses of epinephrine [1 6]. Recent AHA International Consensus Pediatric Resuscitation Guidelines recommend vasopressors for pediatric cardiac arrest, although most pharmacologic agents have little data to support their use [1,7 9]. Many of the AHA recommendations for pediatric resuscitation are based on data extrapolated from studies in adults, animal laboratory experiments, and studies of pediatric resuscitation medications in the non-arrest setting. This experience is supplemented by anecdotal retrospective clinical reports during cardiopulmonary resuscitation (CPR) in children. Lack of data and the continuing dismal outcomes of pediatric arrest drive the search for improved pharmacotherapy of pediatric cardiac arrest [8]. In the recent AHA International Guidelines for Cardiopulmonary Resuscitation and Emergency Cardio /02/$ - see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S (01)

2 150 K. Mann et al. / Resuscitation 52 (2002) vascular Care, vasopressin is recommended as an alternative vasopressor for shock refractory ventricular fibrillation cardiac arrest in adults (Class IIB) [1]. This recommendation was based on extensive animal laboratory data and promising initial out-of-hospital human data in adults in the setting of prolonged CPR and advanced life support. However, no survival benefits were demonstrated in a randomized controlled comparison of early vasopressin versus epinephrine in an adult in-hospital setting with rare ventricular fibrillation, early CPR, early ALS, and early pressor administration [10]. Vasopressin has been reported to exert pressor effects in infants and children in the non-cardiac arrest settings of circulatory shock [11] and during brain death evaluation [12]. However, there are no reports of vasopressin benefit or harm in the specific setting of pediatric cardiac arrest. On the basis of these data, the AHA pediatric recommendation for vasopressin in the setting of cardiac arrest is classified as Indeterminate [1]. The purpose of this retrospective case series is to report successful return of spontaneous circulation after the rescue administration of vasopressin following prolonged cardiac arrest and failure of conventional CPR, advanced life support and epinephrine therapy in children. This clinical series applies evidence of beneficial vasopressin pressor effect extrapolated from laboratory animal studies, adult clinical trials, and pediatric nonarrest settings to the specific setting of pediatric cardiac arrest. Such reports should pave the way for prospective clinical trials comparing vasopressor medications in the setting of pediatric cardiac arrest. 2. Methods All documented episodes of CPR initiated in a 120- bed tertiary care children s hospital from 1997 to 2000 were reviewed for vasopressin administration during CPR with advanced life support. Cardiac arrests with CPR initiated in the pre-hospital setting were excluded. Process and outcome variables were recorded and analyzed using the operational definitions from the in-hospital Utstein style guidelines, modified in accordance to the pediatric Utstein style and pediatric International Liaison Committee on Resuscitation (ILCOR) recommendations [2,7,9]. Cardiopulmonary resuscitation events triggering review by investigators were defined according to Utstein and AHA National Registry of CPR criteria [2,13]: either chest compressions and assisted ventilation provided because of cardiac arrest, or chest compressions provided because of bradycardia with poor perfusion. Cardiac arrest is defined as the cessation of cardiac mechanical activity, determined by the inability to palpate a central pulse, unresponsiveness, and apnea. The major outcome variables included any return of spontaneous circulation (ROSC), ROSC for 20 min, ROSC for 60 min, survival for 24 h and survival to hospital discharge. The end of arrest time was documented, but the exact time that the first spontaneous pulse or blood pressure occurred was not universally documented. This time was extrapolated from nursing notes, progress notes, and the code blue record. Vasopressin was assumed to relate to ROSC only when it was the last medication given before documented ROSC. The patients in this series all received standard AHA CPR and pediatric advanced life support [1] including immediate assisted and invasive ventilation, continuous electrocardiogram (ECG) monitoring, invasive arterial blood pressure monitoring, exhaled CO2 monitoring during resuscitation, immediate intravascular access, and early medication interventions with standard epinephrine dosing (10 mcg/kg) repeated every 3 min. Reversible causes of arrest (e.g. hypoxemia, hypovolemia, hypothermia, hypokalemia, hyperkalemia, toxin or metabolic cause, severe acidosis, tension pneumothorax, tamponade, thromboembolus) were treated if present, early in resuscitation. A board certified pediatric intensive care physician was present and directing care throughout the resuscitation. Vasopressin was administered late in resuscitation as an intervention of last resort at the discretion of the attending physician. In this hospital, standardized pediatric advanced life support protocols are practiced weekly in supervised multidisciplinary mock code scenarios throughout the hospital. Synthetic 8-L-arginine vasopressin (American Regent pharmaceuticals, 20 U/ml, 1 ml/vial) is available on all code carts. Transthoracic defibrillation is provided with an Agilent/HP Codemaster defibrillator delivering a standard damped sinusoidal, monophasic waveform. Peak energy is manually set by protocol to 2 J/kg for initial shocks, and to 4 J/kg for subsequent shocks. A designated in-hospital code blue team responds to arrests with immediate supervision by a board certified pediatric critical care or emergency medicine attending physician. All variables and outcome measures reported are routinely recorded for continuous quality improvement purposes and participation in the AHA National Registry of CPR [13], and families sign consent for use of such data for research review. 3. Results All 70 in-hospital cardiopulmonary resuscitation events documented during the three-year period from 1997 to 2000 were reviewed by two authors independently. Vasopressin was provided in six cardiac arrests among four children. All cardiac arrests in this case series were witnessed and ECG monitored in the pedi-

3 K. Mann et al. / Resuscitation 52 (2002) atric ICU. Vasopressin was only administered after failure to respond to initial conventional CPR and advanced life support, including at least two doses of intravenous epinephrine. The characteristics, interventions and outcomes of the six cardiac arrest events are reported in Table 1. The initial cardiac arrest rhythm was a form of pulseless electrical activity in all six cardiac arrests (ECG= wide complex with rate 50 per minute in three events, narrow complex with rate 50 per minute in two events and wide complex with rate 150 per minute in one event). At the time of vasopressin administration, arrest ECG rhythm was asystole in four events, pulseless ventricular tachycardia in one event, and ventricular fibrillation in one event. The mean duration of CPR was 28.3 min in these six cardiac arrests with vasopressin administration, with a range of min, and a median of 24 min. ROSC occurred in three of four patients (75%), and in four of six cardiac arrests with vasopressin administration (66%). All cardiac arrest victims who responded to vasopressin with ROSC sustained ROSC for 60 min. Two of the four vasopressin recipients (50%) survived 24 h. One survived to hospital discharge with neurologic function close to baseline level of neurologic function on admission (see Section 4). The other 24-h survivor died following family decision to limit and then withdraw ICU technological support. In three of four events where vasopressin resulted in ROSC 60 min, the ROSC occurred after the second 0.4 U/kg dose of vasopressin. In the five events where more than one dose of vasopressin was administered, the mean time between first and second doses of vasopressin was 9.8 min with a range of 3 20 min and a median of 6 min. In the four events where vasopressin administration was associated with ROSC, the mean time from the last dose of vasopressin to ROSC was 2 min with a range of 1 3 min and a median of 2 min. 4. Case example A 5-year-old with cerebral palsy, developmental delay, seizure disorder controlled by ketogenic diet, and nephrolithiasis was admitted with sepsis syndrome. On the third day of hospital admission she developed acute respiratory failure, shock and profound hypotension. Following tracheal intubation, mechanical ventilation, fluid boluses and support with IV epinephrine and dopamine infusions, she was transferred to the pediatric ICU. Fifteen hours later, after stabilization on infusions of central venous epinephrine (1 mcg/kg/min) and dopamine (5 mcg/kg/min), she developed pulseless electrical activity: narrow complex bradycardia without pulses. Immediate effective ventilation via tracheal tube and chest compressions guided by arterial pressure waveform was initiated. Two bolus doses of epinephrine (10 mcg/kg), one dose of atropine (0.02 mg/kg), two doses of high dose epinephrine (100 mcg/ kg), an attempt at transcutaneous pacing, calcium gluconate (50 mg/kg) and a dose of 0.4 U/kg of central venous asopressin did not restore effective spontaneous circulation at 10 min into the resuscitation. ECG rhythm appeared as fine ventricular fibrillation without detectable pulse and was refractory to defibrillation attempts and magnesium sulfate (50 mg/kg). A second dose of 0.4 U/kg Vasopressin was given via central vein and circulated by CPR for 1 min, followed by successful transthoracic defibrillation. ROSC occurred 16 min after the initiation of chest compressions, with a sinus rhythm at a rate of 102/min and blood pressure of 80/52 mmhg. Over the next 5 days she was stabilized and weaned from pressors. She remained on mechanical ventilator dependent secondary to airway obstruction from oral secretions and poor swallowing function. She required tracheostomy and returned close to her developmentally delayed neurologic baseline within 3 months after the arrest. 5. Discussion Cardiopulmonary arrest in children often occurs as a terminal event in the course of a prolonged illness rather than as a primary cardiac event [2 9]. Although nearly two-thirds of children attain ROSC after in-hospital pediatric CPR and approximately one-third survive for 24 h, only 10 18% survive an entire year [5,6]. Cardiac arrest is also uncommon in children. It has been reported that less than 2% of children admitted to a pediatric ICU setting require CPR for 2 min, with survival to hospital discharge following cardiac arrest reported at 13.7% [4]. Despite international consensus pediatric resuscitation guidelines and improvements in pediatric critical care, children who suffer cardiac arrest continue to have a poor prognosis [1 7,14]. There are currently a limited number of medications used in pediatric cardiac arrest and very limited data to support their use [1,8,9]. Although many pharmacologic agents have been proposed, little data exists to support their use in the specific setting of cardiac arrest in children. Much of the data is extrapolated from studies in animal laboratories, adult clinical trials, and usage of these medications in pediatric non-arrest settings. To some extent, this information is often supplemented by anecdotal retrospective clinical case series during CPR in children. The lack of data and the continuing dismal outcomes of pediatric arrest drive the search for improved pharmacotherapy of pediatric cardiac arrest. Following the implementation of the 1992 AHA guidelines [15], the major international resuscitation councils

4 152 K. Mann et al. / Resuscitation 52 (2002) Table 1 Characteristics, interventions and outcomes of four cardiac arrest patients Patient c1 c2 c3 c4 Age 7 months 18 months 3 months 5 years Sex Male Female Male Female Co-morbidities Septic shock; Adult respiratory distress syndrome; Disseminated intravascular Tracheal narrowing; GE Viral pneumonitis; Chronic Septic shock, Delayed coagulopathy; Renal failure reflux; 3 h after cardiac lung disease, GE reflux; development, Seizures arrest at home Prior cardiac arrest at Arrest c c1 c2 c3 c1 home c1 c1 Initial rhythm Wide complex Wide complex Wide complex bradycardia, Narrow complex Wide complex tachycardia, Narrow complex bradycardia, PEA bradycardia, PEA PEA bradycardia, PEA No pulse bradycardia, PEA Rhythm at time Asystole Asystole Asystole Asystole Wide complex tachycardia, Ventricular fibrillation of VP dose No pulse Bolus medication Epinephrine a, Atropine, Epinephrine a, Atropine, Epinephrine a, Epinephrine a, Epinephrine a, Epinephrine a, Epinephrine a, Bicarbonate, Epinephrine a, Epinephrine a, interventions Epinephrine a, Atropine, Epinephrine a, Calcium, Bicarbonate, Atropine, Epinephrine a, Calcium, EPINEPHRINE a, Atropine, Bicarbonate, Bicarbonate, Calcium, Bicarbonate, Calcium, Steroids, Epinephrine a, Bicarbonate, Calcium, Bicarbonate, Calcium, EPINEPHRINE a, Epinephrine a, Calcium, Vasopressin, Vasopressin Bicarbonate, Calcium, Epinephrine a, Atropine, EPINEPHRINE a, Bicarbonate, Bicarbonate, Vasopressin, Vasopressin, Epinephrine a, Vasopressin, Bicarbonate, Calcium, EPINEPHRINE a, Calcium, Vasopressin Glucagon EPINEPHRINE a, Atropine, Magnesium, Lidocaine, Magnesium, Vasopressin, Vasopressin Bicarbonate, Vasopressin, Vasopressin Arrest duration 15 min 12 min 40 min 32 min Amiodarone, Vasopressin 55 min 16 min ROSC 20 min Yes Yes No No Yes Yes Time from 1st 2min 5min N/A N/A 23min 6min VP to ROSC Time from 2nd VP to ROSC N/A 2 min N/A N/A 3min 1min ROSC 60 min Yes Yes No No Yes Yes ROSC 24 h No No No No Yes Yes Hospital Died Died Died after 23 days b Li ed discharge (DNAR) outcome Abbreviations: VP, vasopressin; ROSC, Return of Spontaneous Circulation; PEA, Pulseless Electrical Activity; GE reflux; Gastro-Esophageal Reflux; DNAR, Do Not Attempt Resuscitation. a Epinephrine: dose of 10 mcg/kg IV; EPINEPHRINE: high dose of 100 mcg/kg IV. b Twenty-three days following ROSC, the family decided to establish DNAR orders and withdraw technological support.

5 K. Mann et al. / Resuscitation 52 (2002) developed ILCOR advisory statements reflecting consensus recommendations based on existing resuscitation guidelines, practical experience, and debate of an international resuscitation database [7,9]. Recently, the AHA and ILCOR modified an evidence based review template and applied it to key resuscitation issues in order to update the PALS guidelines, assign classes of recommendations where possible, and objectively attempted to link the class of recommendation to the identified level of evidence [16]. This international evidence based review of advanced life support therapies for cardiac arrest resulted in AHA recommendations for vasopressin as Class IIB in adults and Indeterminate in children for shock refractory ventricular fibrillation cardiac arrest [1]. Vasopressin is an endogenous hormone that acts at specific receptors to cause vasoconstriction. There are three different receptors involved, V1a, V1b, and V2. V1a receptors are localized to the vasculature and, when stimulated, cause vasoconstriction [17,18]. In laboratory animal in estigations using swine cardiac arrest models have established that vasopressin administration during CPR shunts more blood flow to the heart and brain and away from less vital organs, when compared with epinephrine administration [19,20]. Concerns have been raised about the decreased splanchnic blood flow during CPR after vasopressin and worse post-resuscitation myocardial function [21]. Nevertheless, short- and long-term survival in these animal models is consistently superior after vasopressin [22 27]. Recent animal studies indicate that vasopressin is well absorbed via the intravenous, intraosseous or endobronchial routes during CPR. Importantly, the same dose by either of these routes is as effective as an intravenous dose [28,29]. These experimental findings are especially relevant for pediatric resuscitation where intravenous access can be problematic. Data from swine models of pediatric cardiac arrests and asphyxial cardiac arrests are more complex, perhaps due to developmental differences and/or mechanistic differences from adult ventricular fibrillation induced cardiac arrest models. In a piglet model of prolonged cardiac arrest after asphyxia, vasopressin alone during CPR was less effective than epinephrine alone, whereas vasopressin plus epinephrine was as effective as epinephrine alone [30]. Similarly, in a swine model of adult asphyxial cardiac arrest, the combination of vasopressin plus epinephrine resulted in superior coronary perfusion pressure and superior survival when compared with epinephrine alone or vasopressin alone [31]. Finally, in a pediatric porcine model of ventricular fibrillation, the combination of vasopressin and epinephrine resulted in higher left ventricular blood flow than either vasopressin alone or epinephrine alone, and both vasopressin plus epinephrine and vasopressin alone resulted in superior cerebral blood flow compared with epinephrine alone [32]. It is important to note that all of the pediatric patients in this case series received the combination of both vasopressin and epinephrine (i.e. vasopressin rescue following epinephrine failure); none received vasopressin alone. In reported adult cardiac arrest experience, initial evidence of acute beneficial vasopressin pressor effect during CPR for adult cardiac arrest is very encouraging when CPR or advanced life support interventions are delayed or prolonged. In an initial in-hospital case series, ROSC was attained following prolonged CPR in eight patients with rescue vasopressin treatment of ventricular fibrillation refractory to defibrillation attempts and epinephrine. Three of these eight survived to hospital discharge [33]. In a randomized, controlled out-ofhospital trial, 40 adults with delayed CPR, advanced life support interventions, and shock refractory ventricular fibrillation received either 1 mg of epinephrine or 40 U of intravenous vasopressin. Seventy percent (14/ 20) of vasopressin treated patients versus 35% (7/20) of epinephrine treated patients survived to hospital admission (P=0.06). Sixty percent (12/20) of the vasopressin treated patients versus 20% (4/20) of the epinephrine treated patients survived 24 h (P 0.02) [34]. In contrast, there were no differences in outcome from a larger, randomized, controlled in-hospital study comparing early vasopressin versus epinephrine during CPR for adult cardiac arrest. In distinction from the out-ofhospital study, these patients received early CPR, early advanced life support and early vasopressor therapy [10]. Whether vasopressin therapy is beneficial in the setting of adult or pediatric cardiac arrest is still in question. In the non-cardiac arrest setting, clinical use of vasopressin infusions as an effective vasopressor agent in infants and children is well established [11,12]. One retrospective case-control series analyzed 63 critically ill children during brain death evaluation and organ recovery; 34 received very low dose vasopressin infusion for treatment of diabetes insipidus. Children who received vasopressin infusions maintained higher average mean arterial pressures on fewer vasopressor agents than carefully matched controls [12]. Pressor effects of vasopressin were likewise demonstrated in 11 pediatric post-operative cardiac patients with vasodilatory hypotension refractory to high dose pressor infusion therapy [11]. Thus, vasopressin is an effective vasopressor in children, and by extrapolation, may be beneficial in some pediatric cardiac arrest settings. To our knowledge, this is the first case series describing the use of vasopressin during cardiac arrest in children. After high doses of epinephrine and early, appropriate advanced life support interventions had failed to restore spontaneous circulation, the immediate effects of this rescue medication were quite remarkable. Despite the historically poor outcomes following

6 154 K. Mann et al. / Resuscitation 52 (2002) prolonged in-hospital cardiac resuscitation efforts, three of these four patients treated with rescue vasopressin responded with initial ROSC ( 60 min). Two of the four patients survived 24 h despite very prolonged CPR, including multiple doses of epinephrine. These encouraging hemodynamic and short-term benefits of vasopressin are consistent with data from laboratory animal studies, adult human clinical trials and pediatric non-cardiac arrest experience. Although temporal relationships to outcome can be inferred, no single intervention in this in-hospital ICU setting is likely to be solely responsible for successful resuscitation or intact neurologic survival. All cardiac arrests occurred in a pediatric ICU setting where immediate and effective CPR and invasive advanced life support interventions were provided and continuous monitoring was available. Despite this, there was limited response to conventional advanced life support interventions and CPR duration was prolonged. It is difficult to extrapolate this data to a much less controlled, pre-hospital setting. However, it is important to note that vasopressin appeared to exert some beneficial effect, even when administered very late into resuscitation efforts and for rhythms other than ventricular fibrillation. Several limitations are acknowledged. As with all retrospective chart reviews, documentation was occasionally less than optimal and exact time intervals are suspect. Where exact time intervals were not specifically documented, data was extrapolated from each chart by two investigators independently. The end of arrest time was always documented, but the exact time that the first spontaneous pulse or blood pressure occurred was necessarily extrapolated from progress notes, nursing documentation, and code blue data sheets. In addition, case series cannot control for, but can only emphasize the importance of, controlling for potential confounding variables such as duration of arrest, response intervals for CPR and advanced life support interventions, time to first vasopressor, concurrent vasopressor medications, dose, dose interval, and sequence of vasopressor administration. It will be important for future clinical trials to carefully account for these resuscitation variables. Finally, case series only serve as AHA level of evidence 5 (Table 2) [1] or preliminary evidence for intervention effect in cardiac arrest research, and caution regarding enthusiasm for widespread use of vasopressin during cardiac arrest is warranted. 6. Conclusions This case series is the first to report the beneficial effects of vasopressin during pediatric cardiac arrest, in the setting of prolonged in-hospital resuscitation with Table 2 Summary of AHA-emergency cardiovascular care levels of evidence overview Level 1 Level 2 Level 3 Level 4 Le el 5 Level 6 Level 7 Level 8 Positive RCTs: prospective, randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects Neutral RCTs: prospective, randomized clinical trials with smaller or less significant treatment effects Prospective cohort studies: non-randomized, prospective observational study of a group: must have a control group for comparisons Retrospective observational studies with controls; historic, non-randomized, cohort or case-control studies Case series: patients compiled in serial fashion, lacking a control group Animal studies or mechanical model studies (sub-level A indicates study higher quality and better design than sub-level B) Extrapolations from existing data collected for other purposes, theoretical analyses and quasi-experimental designs Rational conjecture (common sense); no evidence of harm, common practices accepted before evidence-based guidelines Abbreviation: RCT, Randomized Controlled Trial. aggressive CPR and advanced life support. Our observations suggest that vasopressin administration can contribute to successful return of spontaneous circulation in children when conventional advanced life support and pressor therapy have failed. Preliminary evidence, like this case series, are important to pave the way for controlled, prospective study of vasopressin in the specific setting of pediatric cardiac arrest. References [1] American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. International consensus on science. Circulation. 2000;102(8) (August). [2] Zaritsky A, Nadkarni VM, Hazinski MF, Foltin G, Quan L, Wright J et al. and the Pediatric Utstein Consensus Panel. Recommended guidelines for uniform reporting of pediatric advanced life support: the pediatric Utstein style. Circulation. 1995;92(7): [3] Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. 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A randomized comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 1997;349: Portuguese Abstract and Keywords As crianças que sofreram paragem cardíaca têm um mau prognóstico. Baseados em estudos animais laboratoriais e em dados clínicos de adultos, a vasopressina surgiu como uma nova modalidade de terapia vasopressora durante a reanimação cardiopulmonar (RCP). A utilização da vasopressina resultou em efeitos benéficos na reanimação a curto prazo em casos de paragem cardíaca por fibrilhação ventricular em adultos fora do hospital. Esta série retrospectiva representa a primeira evidência dos efeitos benéficos da terapêutica com a vasopressina no caso específico da paragem cardíaca pediátrica. Foram revistos todos os casos de RCP iniciados num hospital pediátrico terciário de 120 camas durante um período de 3 anos ( ). Quatro crianças na UCI (Unidade de Cuidados Intensivos Pediátrica) receberam bolus de vasopressina como terapêutica de salvamento durante seis episódios de paragem cardíaca depois de as manobras convencionais de RCP, suporte avançado de vida e terapêutica vasopressora com epinefrina, terem falhado. O retorno de circulação espontânea por mais de 60 minutos ocorreu em três de

8 156 K. Mann et al. / Resuscitation 52 (2002) quatro doentes (75%) e em quatro de seis episódios de RCP (66%) após a administração de vasopressina. Dois de quatro receptores de vasopressina sobreviveram mais de 24 horas; um sobreviveu à alta hospitalar e num outro foram suspensas as medidas terapêuticas de suporte após discussão com a família. Estas observações são nível 5 da AHA (Uma série de casos retrospectivos) que evidenciam que a administração de vasopressina pode ser benéfica durante paragens cardíacas pediátricas prolongadas. Estes relatos devem abrir o caminho para a realização de estudos clínicos prospectivos comparando medicamentos vasopressores no contexto de paragem cardíaca pediátrica. Pala ras cha e: Vasopressina; Reanimação; Paragem cardíaca; Reanimação cardiopulmonar (RCP); Crianças; Pediatria; Epinefrina; Terapêutica vasopressora Spanish Abstract and Keywords Los niños que sufren paro cardíaco tienen un pronóstico pobre. En base a estudios de laboratorio y datos clínicos en adultos, la vasopresina es una nueva modalidad de tratamiento vasopresor durante la resucitación cardiopulmonar (CPR). En particular, la vasopresina ha resultado en beneficios a corto plazo en la resucitación como un agente presor de rescate en la escena de fibrilación ventricular en adultos con CPR extrahospitalaria prologada. Esta serie retrospectiva presenta la primera evidencia para los beneficios de terapia con bolos de vasopresina en el caso específico de paro cardíaco pediátrico. Se revisaron todos los episodios de CPR ocurridos en un período de tres años ( ) en un hospital pediátrico de cuidados terciarios con 120 camas. Cuatro niños en la unidad de cuidados intensivos (ICU) recibieron bolos de vasopresina como terapia de rescate durante seis eventos de paro cardíaco, después del fracaso de la CPR convencional, soporte vital avanzado, y terapia vasopresora con adrenalina. Hubo retorno a circulación espontánea después de la administración de vasopresina en tres de cuatro pacientes (75%) y en cuatro de seis eventos de CPR (66%). Dos de cuatro receptores de vasopresina sobrevivieron 24 horas; uno sobrevivió al alta y a uno se le suspendieron las terapias de soporte después de discusión con la familia. Nuestras observaciones son evidencia de nivel 5 de la AHA (series de casos retrospectivas) que apoya que la administración de vasopresina puede ser beneficiosa durante el paro cardíaco pediátrico prolongado. Estos reportes allanan el camino para ensayos clínicos prospectivos comparando la medicación vasopresora en paro cardíaco pediátrico. Palabras cla e: Vasopresina; Resucitación; Paro Cardíaco; Resucitación cardiopulmonar (CPR) R CP; niños; Pediatrico; Adrenalina; Terapia vasopresora