Transcript Peds 819 TF - Heart Volunteer

Dallas 2015
Peds 819 : Pre-arrest Care of Pediatric
Dilated Cardiomyopathy or Myocarditis
TFQO: Vinay Nadkarni MD COI#249
EVREV 1: Graeme Maclaren MBBS COI#98
EVREV 2: Ravi Thiagarajan MBBS, MPH COI#149
Taskforce: PALS
COI Disclosure
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(SPECIFIC to this systematic review)
Graeme Maclaren COI#98
Commercial/industry
• None
Potential intellectual conflicts
• Chairman, Asia-Pacific Chapter, ELSO
Ravi Thiagarajan COI#149
Commercial/industry
• Bristol Myers Squibb (Events adjudication committee)
Potential intellectual conflicts
• ELSO registry Co-Chair
2010 Treatment
Recommendation
“Topic not reviewed in 2010”.
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C2015 PICO
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Population: Pediatric patients with dilated
Cardiomyopathy (DCM) or Myocarditis in a
pre-arrest state
Intervention: Any Pre-Arrest management
Comparison: Standard care/No treatment
Outcomes:
9-Critical
7-Critical
5-Important
5-Important
Survival with Favorable neurological/
functional outcome at discharge, 30 days,
60 days, 180 days AND/OR 1 year
Survival to hospital discharge
Cardiac arrest frequency
ROSC
Inclusion/Exclusion
& Articles Found
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Inclusions: Dilated Cardiomyopathy, Myocarditis,
Children, shock, pre-arrest, cardiac arrest, prearrest treatment. We searched for RCTs and
observational studies. We excluded studies with
only post-arrest management
Number of Articles
Search Identified: 548 articles
Initial review: 67 article (2 RCTs; 65 Non-RCTs);
Excluded: 481
Final Inclusion: 5 articles (All Non-RCTs; 1 not
identified from initial search); Excluded 62
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Included Articles
Lynch, Johanne; Pehora, Carolyne; Holtby, Helen; Schwarz, Steven M; Taylor,
Katherine;Cardiac arrest upon induction of anesthesia in children with
cardiomyopathy: an analysis of incidence and risk factors. Paediatr Anaesth Sep
2011; 21 (9): 951-7.
Song, M.-K.;Baek, J.-S.;Kwon, B.-S.;Kim, G.-B.;Bae, E.-J.;Noh, C.-I.;Choi, J.-Y. Clinical
spectrum and prognostic factors of pediatric ventricular tachycardia. : Circ. J.
2010; 74 (9): 1951-1958
Eicken, Andreas; Kolb, Christof; Lange, Sylvia; Brodherr-Heberlein, Silke; Zrenner,
Bernhard; Schreiber, Christian; Hess, John. Implantable cardioverter defibrillator
(ICD) in children. Int. J. Cardiol. Feb-8-2006; 107 (1): 30-5.
Greissman, A.;Silver, P.;Nimkoff, L.;Sagy, M. . Transvenous right ventricular pacing
during cardiopulmonary resuscitation of pediatric patients with acute
cardiomyopathy. PEDIATR. EMERG. CARE 1995; 11 (1): 17-24.
Teele SA, Allan CK, Laussen PC, Newburger JW, Gauvreau K, Thiagarajan RR.
Management and Outcomes in Pediatric Patients Presenting with Acute
Fulminant Myocarditis. J Pediatr. 2011 Apr;158(4):638-643
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2015 Proposed
Treatment Recommendations
We suggest Implantable Cardiac Defibrillator (ICD) and
Anti-arrhythmic medications for pre-arrest management
of cardiac arrest in pediatric dilated cardiomyopathy or
myocarditis (weak recommendation, very low quality
evidence)
We suggest use of ECMO for patients with myocarditis
presenting with dysrhythmia, lactic acidosis, renal, or
hepatic dysfunction for consideration of ECMO (weak
recommendation, very low quality evidence)
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Risk of Bias in studies
Eligibility Criteria
Exposure/Outcome
Confounding
Follow up
Non-RCT bias asssesment
Low
Low
Unclear
Low
Song
2010 Non-RCT
81
VT
No
Low
Low
High
Low
Eicken
2006 Non-RCT
16
AICD patients
No
Low
Low
High
Low
Greissman
1995 Non-RCT
5
IHCA
No
Low
Low
High
Low
Teele
2011 Non-RCT
20
Myocarditis
No
Low
Low
High
Low
Study
Lynch
Year
2011
Design
Total
Patients
Population
Industry
Funding
Non-RCT
129
Cardiomyopathy/P
re-arrest
No
No RCTs Included
Evidence profile table(s)
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Proposed
Consensus on Science statements
1.
2.
3.
4.
For the critical outcome of survival to hospital discharge, we have identified no clinical
evidence that a specific pre-arrest management strategy in children with dilated
cardiomyopathy (DCM) or myocarditis shows a benefit (Song, 2010,
1951; Eicken, 2006, 30)
For the critical outcome of survival to hospital discharge, we have identified no clinical
evidence that a specific anesthetic in patients with dilated cardiomyopathy shows
benefit. The incidence of cardiac arrest in patient with DCM undergoing procedural
anesthesia is relatively low (1.7%). (Lynch, 2011, 951).
For the critical outcome of survival with good neurological outcome, we have identified
very low quality limited clinicial evidence from an observational study of 12 children
with dilated cardiomyopathy or myocarditis, and documented ventricular tachycardia,
that use of ICD or anti-arrhythmic agents may not lead to improved outcome. The risk
of inappropriate shock and complications could not be estimated from the study.
(Song, 2010, 1951)
For the critical outcome of survival to hospital discharge, we have identified very low
quality evidence from an observational study of 20 children with acute myocarditis that
demonstrated that the use of ECMO after cardiac arrest may lead to improved
outcomes. Cardiac arrest and/or need for ECMO was associated with those presenting
with dysrhythmia, lactic acidosis, renal, or liver dysfunction, (Teele, 2011, 638).
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Draft
Treatment Recommendations
We suggest for children with myocarditis presenting with
high risk features (Arrhythmia, Lactic acidosis, Renal and
liver dysfunction) that ECMO may be used in the pre-arrest
management where the appropriate resources are available
(weak recommendation based on very low quality evidence)
There is insufficient evidence upon which to base a
recommendation for the empiric use of ICD or any specific
anti-arrhythmia medications for children with dilative
cardiomyopathy or myocarditis in a pre-arrest state. (weak
recommendation based on very low quality evidence)
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Knowledge Gaps
Factors associated with cardiac arrest in
patients with DCM or myocarditis have not
been studied
There is little knowledge on benefits of prearrest initiation of inotropes/inodilators,
mechanical ventilation, or ECMO on survival
and neurological outcomes in children with
DCM or myocarditis