Part 10: Pediatric Basic and Advanced Life Support
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 16_suppl_2 Linguagem: Inglês
10.1161/circulationaha.110.971093
ISSN1524-4539
AutoresMonica E. Kleinman, Allan R. de Caen, Leon Chameides, Dianne L. Atkins, Robert A. Berg, Marc Berg, Farhan Bhanji, Dominique Biarent, Robert Bingham, Ashraf Coovadia, Mary Fran Hazinski, Robert W. Hickey, Vinay Nadkarni, Amélia G. Reis, Antonio Rodríguez‐Núñez, James Tibballs, Arno Zaritsky, David Zideman, Ian Adatia, Richard Aickin, John Berger, Jeffrey M. Berman, Desmond Bohn, Kate Brown, M G Coulthard, Douglas S. Diekema, Aaron Donoghue, Jonathan P. Duff, Jonathan R. Egan, Christoph Eich, Diana G. Fendya, Ericka L. Fink, Loh Tsee Foong, Eugene B. Freid, Susan Fuchs, Anne‐Marie Guerguerian, Bradford D. Harris, George M. Hoffman, James S. Hutchison, Sharon Kinney, Sasa Kurosawa, Jesús López‐Herce, Sharon E. Mace, Ian Maconochie, Duncan Macrae, Mioara D. Manole, Bradley S. Marino, Felipe Martínez, Reylon A. Meeks, Alfredo Misraji, Marilyn C. Morris, Akira Nishisaki, Masahiko Nitta, Gabrielle Nuthall, Sergio Pesutic Perez, Lester T. Proctor, Faiqa Qureshi, Sergio Rendich, Ricardo A. Samson, Kennith H. Sartorelli, Stephen M. Schexnayder, W. G. Scott, Vijay Srinivasan, Robert M. Sutton, Mark Terry, Shane M. Tibby, Alexis A. Topjian, Élise W. van der Jagt, David Wessel,
Tópico(s)Respiratory Support and Mechanisms
ResumoHomeCirculationVol. 122, No. 16_suppl_2Part 10: Pediatric Basic and Advanced Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 10: Pediatric Basic and Advanced Life Support2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Monica E. Kleinman, Allan R. de Caen, Leon Chameides, Dianne L. Atkins, Robert A. Berg, Marc D. Berg, Farhan Bhanji, Dominique Biarent, Robert Bingham, Ashraf H. Coovadia, Mary Fran Hazinski, Robert W. Hickey, Vinay M. Nadkarni, Amelia G. Reis, Antonio Rodriguez-Nunez, James Tibballs, Arno L. Zaritsky, David Zideman, Pediatric Basic and Advanced Life Support Chapter Collaborators Ian Adatia, Richard P. Aickin, John Berger, Jeffrey M. Berman, Desmond Bohn, Kate L. Brown, Mark G. Coulthard, Douglas S. Diekema, Aaron Donoghue, Jonathan Duff, Jonathan R. Egan, Christoph B. Eich, Diana G. Fendya, Ericka L. Fink, Loh Tsee Foong, Eugene B. Freid, Susan Fuchs, Anne-Marie Guerguerian, Bradford D. Harris, George M. Hoffman, James S. Hutchison, Sharon B. Kinney, Sasa Kurosawa, Jesús Lopez-Herce, Sharon E. Mace, Ian Maconochie, Duncan Macrae, Mioara D. Manole, Bradley S. Marino, Felipe Martinez, Reylon A. Meeks, Alfredo Misraji, Marilyn Morris, Akira Nishisaki, Masahiko Nitta, Gabrielle Nuthall, Sergio Pesutic Perez, Lester T. Proctor, Faiqa A. Qureshi, Sergio Rendich, Ricardo A. Samson, Kennith Sartorelli, Stephen M. Schexnayder, William Scott, Vijay Srinivasan, Robert M. Sutton, Mark Terry, Shane Tibby, Alexis Topjian, Elise W. van der Jagt and David Wessel Monica E. KleinmanMonica E. Kleinman , Allan R. de CaenAllan R. de Caen , Leon ChameidesLeon Chameides , Dianne L. AtkinsDianne L. Atkins , Robert A. BergRobert A. Berg , Marc D. BergMarc D. Berg , Farhan BhanjiFarhan Bhanji , Dominique BiarentDominique Biarent , Robert BinghamRobert Bingham , Ashraf H. CoovadiaAshraf H. Coovadia , Mary Fran HazinskiMary Fran Hazinski , Robert W. HickeyRobert W. Hickey , Vinay M. NadkarniVinay M. Nadkarni , Amelia G. ReisAmelia G. Reis , Antonio Rodriguez-NunezAntonio Rodriguez-Nunez , James TibballsJames Tibballs , Arno L. ZaritskyArno L. Zaritsky , David ZidemanDavid Zideman , Pediatric Basic and Advanced Life Support Chapter Collaborators , Ian AdatiaIan Adatia , Richard P. AickinRichard P. Aickin , John BergerJohn Berger , Jeffrey M. BermanJeffrey M. Berman , Desmond BohnDesmond Bohn , Kate L. BrownKate L. Brown , Mark G. CoulthardMark G. Coulthard , Douglas S. DiekemaDouglas S. Diekema , Aaron DonoghueAaron Donoghue , Jonathan DuffJonathan Duff , Jonathan R. EganJonathan R. Egan , Christoph B. EichChristoph B. Eich , Diana G. FendyaDiana G. Fendya , Ericka L. FinkEricka L. Fink , Loh Tsee FoongLoh Tsee Foong , Eugene B. FreidEugene B. Freid , Susan FuchsSusan Fuchs , Anne-Marie GuerguerianAnne-Marie Guerguerian , Bradford D. HarrisBradford D. Harris , George M. HoffmanGeorge M. Hoffman , James S. HutchisonJames S. Hutchison , Sharon B. KinneySharon B. Kinney , Sasa KurosawaSasa Kurosawa , Jesús Lopez-HerceJesús Lopez-Herce , Sharon E. MaceSharon E. Mace , Ian MaconochieIan Maconochie , Duncan MacraeDuncan Macrae , Mioara D. ManoleMioara D. Manole , Bradley S. MarinoBradley S. Marino , Felipe MartinezFelipe Martinez , Reylon A. MeeksReylon A. Meeks , Alfredo MisrajiAlfredo Misraji , Marilyn MorrisMarilyn Morris , Akira NishisakiAkira Nishisaki , Masahiko NittaMasahiko Nitta , Gabrielle NuthallGabrielle Nuthall , Sergio Pesutic PerezSergio Pesutic Perez , Lester T. ProctorLester T. Proctor , Faiqa A. QureshiFaiqa A. Qureshi , Sergio RendichSergio Rendich , Ricardo A. SamsonRicardo A. Samson , Kennith SartorelliKennith Sartorelli , Stephen M. SchexnayderStephen M. Schexnayder , William ScottWilliam Scott , Vijay SrinivasanVijay Srinivasan , Robert M. SuttonRobert M. Sutton , Mark TerryMark Terry , Shane TibbyShane Tibby , Alexis TopjianAlexis Topjian , Elise W. van der JagtElise W. van der Jagt and David WesselDavid Wessel Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.971093Circulation. 2010;122:S466–S515Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, "Family Presence During ResuscitationPeds-003"). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.The 2010 ILCOR Pediatric Task Force experts developed 55 questions related to pediatric resuscitation. Topics were selected based on the 2005 Consensus on Science and Treatment Recommendations (CoSTR) document,1,2 emerging science, and newly identified issues. Not every topic reviewed for the 2005 International Consensus on Science was reviewed in the 2010 evidence evaluation process. In general, evidence-based worksheets were assigned to at least 2 authors for each topic. The literature search strategy was first reviewed by a "worksheet expert" for completeness. The expert also approved the final worksheet to ensure that the levels of evidence were correctly assigned according to the established criteria. Worksheet authors were requested to draft CoSTR statements (see Part 3: Evidence Evaluation Process). Each worksheet author or pair of authors presented their topic to the Task Force in person or via a webinar conference, and Task Force members discussed the available science and revised the CoSTR draft accordingly. These draft CoSTR summaries were recirculated to the International Liaison Committee on Resuscitation (ILCOR) Pediatric Task Force for further refinement until consensus was reached. Selected controversial and critical topics were presented at the 2010 ILCOR International Evidence Evaluation conference in Dallas, Texas, for further discussion to obtain additional input and feedback. This document presents the 2010 international consensus on the science, treatment, and knowledge gaps for each pediatric question.The most important changes or points of emphasis in the recommendations for pediatric resuscitation since the publication of the 2005 ILCOR International Consensus on CPR and ECC Science With Treatment Recommendations1,2 are summarized in the following list. The scientific evidence supporting these changes is detailed in this document.Additional evidence shows that healthcare providers do not reliably determine the presence or absence of a pulse in infants or children.New evidence documents the important role of ventilations in CPR for infants and children. However, rescuers who are unable or unwilling to provide ventilations should be encouraged to perform compression-only CPR.To achieve effective chest compressions, rescuers should compress at least one third the anterior-posterior dimension of the chest. This corresponds to approximately 1½ inches (4 cm) in most infants and 2 inches (5 cm) in most children.When shocks are indicated for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in infants and children, an initial energy dose of 2 to 4 J/kg is reasonable; doses higher than 4 J/kg, especially if delivered with a biphasic defibrillator, may be safe and effective.More data support the safety and effectiveness of cuffed tracheal tubes in infants and young children, and the formula for selecting the appropriately sized cuffed tube was updated.The safety and value of using cricoid pressure during emergency intubation are not clear. Therefore, the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation.Monitoring capnography/capnometry is recommended to confirm proper endotracheal tube position.Monitoring capnography/capnometry may be helpful during CPR to help assess and optimize quality of chest compressions.On the basis of increasing evidence of potential harm from exposure to high-concentration oxygen after cardiac arrest, once spontaneous circulation is restored, inspired oxygen concentration should be titrated to limit the risk of hyperoxemia.Use of a rapid response system in a pediatric inpatient setting may be beneficial to reduce rates of cardiac and respiratory arrest and in-hospital mortality.Use of a bundled approach to management of pediatric septic shock is recommended.The young victim of a sudden, unexpected cardiac arrest should have an unrestricted, complete autopsy, if possible, with special attention to the possibility of an underlying condition that predisposes to a fatal arrhythmia. Appropriate preservation and genetic analysis of tissue should be considered; detailed testing may reveal an inherited "channelopathy" that may also be present in surviving family members.SystemsMedical emergency teams (METs) or rapid response teams (RRTs) have been shown to be effective in preventing respiratory and cardiac arrests in selected pediatric inpatient settings.Family presence during resuscitations has been shown to be beneficial for the grieving process and in general was not found to be disruptive. Thus, family presence is supported if it does not interfere with the resuscitative effort.Medical Emergency or Rapid Response TeamPeds-025A, Peds-025BConsensus on ScienceThe introduction of METs or RRTs was associated with a decrease in pediatric hospital mortality in 1 LOE 3 meta-analysis3 and 3 pediatric LOE 3 studies with historic controls.4–6 The introduction of a MET or RRT was associated with a decrease in respiratory but not cardiac arrest in 1 LOE 37 study with historic controlsa decrease in preventable total number of arrests in 1 LOE 3 study compared with a retrospective chart review8a decrease in total number of arrests in 2 LOE 34,8 studiesa decrease in preventable cardiac arrests in 1 LOE 36 studya decrease in cardiac arrest and non–pediatric intensive care unit (PICU) mortality in 1 LOE 39 pediatric cohort study using historical controlsTreatment RecommendationsPediatric RRT or MET systems may be beneficial to reduce the risk of respiratory and/or cardiac arrest in hospitalized pediatric patients outside an intensively monitored environment.Knowledge GapsIs it the team or the staff education associated with MET or RRT implementation that leads to improved patient outcomes? Is the team effectiveness due to validated team activation criteria or specific team composition? Do the benefits attributed to these teams extend to children in a community hospital setting?Family Presence During ResuscitationPeds-003Consensus on ScienceTen studies (LOE 210; LOE 311; LOE 412–19) documented that parents wish to be given the option of being present during the resuscitation of their children. One LOE 2,10 1 LOE 3,11 2 LOE 4,13,19 and 1 LOE 520 studies confirmed that most parents would recommend parent presence during resuscitation.One LOE 2,10 1 LOE 3,11 6 LOE 4,12,14,19,21–23 and 2 LOE 520,24 studies of relatives present during the resuscitation of a family member reported that they believed their presence was beneficial to the patient.One LOE 2,10 1 LOE 3,11 6 LOE 4,12,13,16–19 and 1 LOE 524 studies reported that most relatives present during the resuscitation of a family member benefited from the experience. One LOE 3,11 4 LOE 4,12,13,20,21 and 2 LOE 524,25 studies reported that being present during the resuscitation helped their adjustment to the family member's death.One LOE 210 and 2 LOE 412,13 studies observed that allowing family members to be present during a resuscitation in a hospital setting did them no harm, whereas 1 LOE 426 study suggested that some relatives present for the resuscitation of a family member experienced short-term emotional difficulty.One LOE 2,10 1 LOE 3,27 3 LOE 4,12,23,28 and 3 LOE 520,24,29 studies showed that family presence during resuscitation was not perceived as being stressful to staff or to have negatively affected staff performance. However, 1 survey (LOE 430) found that 39% to 66% of emergency medical services (EMS) providers reported feeling threatened by family members during an out-of-hospital resuscitation and that family presence interfered with their ability to perform resuscitations.Treatment RecommendationsIn general, family members should be offered the opportunity to be present during the resuscitation of an infant or child. When deciding whether to allow family members to be present during an out-of-hospital resuscitation, the potential negative impact on EMS provider performance must be considered.Knowledge GapsHow does the presence of a dedicated support person help family members and, potentially, healthcare providers during the resuscitation of an infant or child? What training is appropriate for staff who may serve as support persons for family members during resuscitation of an infant or child? Why is family presence during resuscitation perceived more negatively by out-of-hospital care providers than by in-hospital staff?AssessmentMany healthcare providers find it difficult to rapidly and accurately determine the presence or absence of a pulse. On the basis of available evidence, the Task Force decided to deemphasize but not eliminate the pulse check as part of the healthcare provider assessment. The Task Force members recognized that healthcare providers who work in specialized settings may have enhanced skills in accurate and rapid pulse checks, although this has not been studied.There are considerable data regarding use of end-tidal carbon dioxide (Petco2) measurement, capnography and capnometry, during cardiopulmonary resuscitation (CPR) as an indicator of CPR quality and as a predictive measure of outcome. Although capnography/capnometry may reflect the quality of CPR, there is insufficient evidence of its reliability in predicting resuscitation success in infants and children.Pulse Check Versus Check for Signs of LifePeds-002AConsensus on ScienceThirteen LOE 5 studies31–43 observed that neither laypersons nor healthcare providers are able to perform an accurate pulse check in healthy adults or infants within 10 seconds. In 2 LOE 5 studies in adults44,45 and 2 LOE 3 studies in children with nonpulsatile circulation,46,47 blinded healthcare providers commonly assessed pulse status inaccurately and their assessment often took >10 seconds. In the pediatric studies, healthcare professionals were able to accurately detect a pulse by palpation only 80% of the time. They mistakenly perceived a pulse when it was nonexistent 14% to 24% of the time and failed to detect a pulse when present in 21% to 36% of the assessments. The average time to detect an actual pulse was approximately 15 seconds, whereas the average time to confirm the absence of a pulse was 30 seconds. Because the pulseless patients were receiving extracorporeal membrane oxygenation (ECMO) support, one must be cautious in extrapolating these data to the arrest situation; all pulseless patients did have perfusion and therefore had signs of circulation as evidenced by warm skin temperature with brisk capillary refill. All patients evaluated were in an intensive care unit (ICU) setting without ongoing CPR.Treatment RecommendationsPalpation of a pulse (or its absence) is not reliable as the sole determinant of cardiac arrest and need for chest compressions. If the victim is unresponsive, not breathing normally, and there are no signs of life, lay rescuers should begin CPR. In infants and children with no signs of life, healthcare providers should begin CPR unless they can definitely palpate a pulse within 10 seconds.Knowledge GapsIs there an association between the time required to successfully detect a suspected cardiac arrest victim's pulse and resuscitation outcome? Is there a difference in outcome when the decision to start chest compressions is based on the absence of signs of life as opposed to absence of a pulse?Focused Echocardiogram to Detect Reversible Causes of Cardiac ArrestPeds-006BConsensus on ScienceIn 1 small LOE 4 pediatric case series48 cardiac activity was rapidly visualized by echocardiography without prolonged interruption of chest compressions, and this cardiac activity correlated with the presence or absence of a central pulse. In 1 pediatric LOE 4 case report,49 echocardiography was useful for diagnosing pericardial tamponade as the cause of cardiac arrest and was useful in guiding treatment.In 8 LOE 5 adult case series,50–57 echocardiographic findings correlated well with the presence or absence of cardiac activity in cardiac arrest. These reports also suggested that echocardiography may be useful in identifying patients with potentially reversible causes for the arrest.Treatment RecommendationsThere is insufficient evidence to recommend for or against the routine use of echocardiography during pediatric cardiac arrest. Echocardiography may be considered to identify potentially treatable causes of an arrest when appropriately skilled personnel are available, but the benefits must be carefully weighed against the known deleterious consequences of interrupting chest compressions.Knowledge GapsCan echocardiography be performed during cardiac arrest in infants and children without significant interruptions in chest compressions? How often does echocardiography during cardiac arrest provide information that can affect treatment and outcome?End-tidal CO2 (Petco2) and Quality of CPRPeds-005A, Peds-005BConsensus on ScienceThree LOE 5 animal studies,58–60 4 LOE 5 adult,61–64 and 1 LOE 5 pediatric series65 showed a strong correlation between Petco2 and interventions that increase cardiac output during resuscitation from shock or cardiac arrest. Similarly 3 LOE 5 animal models66–68 showed that measures that markedly reduce cardiac output result in a fall in Petco2.Two LOE 5 adult out-of-hospital studies69,70 supported continuous Petco2 monitoring during CPR as a way of determining return of spontaneous circulation (ROSC), particularly if the readings during CPR are >15 mm Hg (2.0 kPa). In 1 LOE 471 and 2 LOE 5 adult case series,72,73 an abrupt and sustained rise in Petco2 often preceded identification of ROSC.Two LOE 4 pediatric cases series,65,74 8 LOE 5 adult,70,75–81 and 1 LOE 5 animal study59 showed that a low Petco2 (<10 mm Hg [1.33 kPa] to <15 mm Hg [2.0 kPa]) despite 15 to 20 minutes of advanced life support (ALS) is strongly associated with failure to achieve ROSC. On the basis of 2 LOE 5 animal studies71,82 and 2 adult LOE 5 case series,70,78 Petco2 after at least 1 minute of CPR may be more predictive of outcome than the initial value because the initial Petco2 is often increased in patients with asphyxial cardiac arrest.The wide variation for initial Petco2 during resuscitation limits its reliability in predicting outcome of resuscitation and its value as a guide to limiting resuscitation efforts. Two LOE 5 animal studies71,82 and 2 large LOE 5 adult trials70,78 suggested that the initial Petco2 is higher if the etiology of the cardiac arrest is asphyxial rather than if it is a primary cardiac arrest.Interpretation of the end-tidal CO2 during resuscitation is affected by the quality of the measurement, the minute ventilation delivered during resuscitation, the presence of lung disease that increases anatomic dead space, and the presence of right-to-left shunting.83–85In 1 LOE 5 adult study,86 sodium bicarbonate transiently increased end-tidal CO2, and in 3 LOE 5 adult87–89 and 2 LOE 5 animal90,91 studies, epinephrine (and other systemic vasoconstrictive agents) transiently decreased Petco2.Treatment RecommendationsContinuous capnography or capnometry monitoring, if available, may be beneficial by providing feedback on the effectiveness of chest compressions. Whereas a specific target number cannot be identified, if the Petco2 is consistently <15 mm Hg, it is reasonable to focus efforts on improving the quality of chest compressions and avoiding excessive ventilation.Although a threshold Petco2 may predict a poor outcome from resuscitation and might be useful as a guide to termination of CPR, there are insufficient data to establish the threshold and the appropriate duration of ALS needed before such evaluation in children. The Petco2 must be interpreted with caution for 1 to 2 minutes after administration of epinephrine or other vasoconstrictive medications because these medications may decrease the Petco2.Knowledge GapsDoes Petco2 monitoring during CPR improve quality of chest compressions and/or outcome of pediatric resuscitation? During CPR, can Petco2 be reliably measured via a laryngeal mask airway (LMA)? Is there a threshold Petco2 that predicts ROSC or low likelihood of ROSC during resuscitation from pediatric cardiac arrest? Can the initial Petco2 distinguish asphyxial from cardiac etiology of pediatric cardiac arrest? Is detection of ROSC using Petco2 monitoring more accurate than palpation of a pulse? Are Petco2 targets during CPR different for subgroups of infants and children with alterations in pulmonary blood flow or high airway resistance?Airway and VentilationOpening and maintaining a patent airway and providing ventilations are fundamental elements of pediatric CPR, especially because cardiac arrest often results from, or is complicated by, asphyxia. There are no new data to change the 2005 ILCOR recommendation to use manual airway maneuvers (with or without an oropharyngeal airway) and bag-mask ventilation (BMV) for children requiring airway control or positive-pressure ventilation for short periods in the out-of-hospital setting. When airway control or BMV is not effective, supraglottic airways may be helpful when used by properly trained personnel.When performing tracheal intubation, data suggest that the routine use of cricoid pressure may not protect against aspiration and may make intubation more difficult.Routine confirmation of tracheal tube position with capnography/capnometry is recommended with the caveat that the Petco2 in infants and children in cardiac arrest may be below detection limits for colorimetric devices.Following ROSC, toxic oxygen byproducts (reactive oxygen species, free radicals) are produced that may damage cell membranes, proteins, and DNA (reperfusion injury). Although there are no clinical studies in children (outside the newborn period) comparing different concentrations of inspired oxygen during and immediately after resuscitation, animal data and data from newborn resuscitation studies suggest that it is prudent to titrate inspired oxygen after return of a perfusing rhythm to prevent hyperoxemia.Supplementary OxygenPeds-015Consensus on ScienceThere are no studies comparing ventilation of infants and children in cardiac arrest with different inspired oxygen concentrations. Two LOE 5 meta-analyses of several randomized controlled trials comparing neonatal resuscitation initiated with room air versus 100% oxygen92,93 showed increased survival when resuscitation was initiated with room air.Seven LOE 5 animal studies94–100 suggested that ventilation with room air or an Fio2 of <1.0 during cardiac arrest may be associated with less neurologic deficit than ventilation with an Fio2 of 1.0, whereas 1 LOE 5 animal study101 showed no difference in outcome. In 5 LOE 5 animal studies95,97–99,102 ventilation with 100% oxygen during and following resuscitation contributed to free radical–mediated reperfusion injury to the brain.Treatment RecommendationsThere is insufficient evidence to recommend any specific inspired oxygen concentration for ventilation during resuscitation from cardiac arrest in infants and children. Once circulation is restored, it is reasonable to titrate inspired oxygen to limit hyperoxemia.Knowledge GapsDoes the use of any specific concentration of supplementary oxygen during resuscitation from cardiac arrest in infants and children improve or worsen outcome? What is the appropriate target oxygen saturation for the pediatric patient after achieving ROSC?Cuffed Versus Uncuffed Tracheal TubePeds-007Consensus on ScienceThere are no studies that compare the safety and efficacy of cuffed versus uncuffed tubes in infants and children who require emergency intubation.Two LOE 5 randomized controlled studies103,104 and 1 LOE 5 cohort-controlled study105 in a pediatric anesthesia setting showed that the use of cuffed tracheal tubes was associated with a higher likelihood of selecting the correct tracheal tube size (and hence a lower reintubation rate) with no increased risk of perioperative or airway complications. Cuff pressures in these 3 studies were maintained at 8 years of age who were intubated with cuffed compared with uncuffed tracheal tubes.One small LOE 5 case-controlled study111 showed that cuffed tracheal tubes decreased the incidence of aspiration in the PICU, and 1 LOE 5 case series105 of children with burns undergoing general anesthesia showed a significantly higher rate of excessive air leak requiring immediate reintubation in patients initially intubated with an uncuffed tracheal tube.Treatment RecommendationsBoth cuffed and uncuffed tracheal tubes are acceptable for infants and children undergoing emergency intubation. If cuffed tracheal tubes are used, avoid excessive cuff pressures.Knowledge GapsWhat is the best technique to determine cuff pressure and/or the presence of an air leak when using cuffed tracheal tubes in infants and children? What is the optimal cuff or leak pressure for children of different ages? Does optimal cuff pressure vary based on the type of cuffed tube (eg, Microcuff®) used?Are the data generated in elective operating room studies applicable to emergency resuscitation scenarios? Are there select populations of pediatric patients whose outcomes are improved by the use of cuffed tracheal tubes during resuscitation?Tracheal Tube SizePeds-057A, Peds-057BConsensus on ScienceEvidence from 1 LOE 2 prospective randomized trial of elective intubation in a pediatric operating room103 was used to support the existing formula for estimation of appropriate cuffed tracheal tube internal diameter (ID): ID (mm)=(age in years/4) + 3, also known as the Khine formula. Detailed analysis of this paper, however, reveals that the aggressive rounding up of age employed by the authors in their calculations commonly resulted in selection of a tube with an ID 0.5 mm larger than the size derived from the formula.Evidence from 1 LOE 2 prospective randomized multicenter study,104 1 LOE 2,112 and 3 LOE 4 prospective observational studies of elective intubation in the pediatric operating room113–115 supported use of 3-mm ID cuffed tracheal tubes for newborns and infants (3.5 kg to 1 year of age) and 3.5-mm ID cuffed tracheal tubes for patients 1 to 2 years of age.One LOE 2 prospective randomized multicenter study104 and 3 LOE 4 prospective observational studies of elective intubation in the pediatric operating room113–115 using Microcuff® tracheal tubes support the use of the following formula for cuffed endotracheal tubes in children: ID (mm)=(age/4) + 3.5. One LOE 2 prospective observational study of elective intubation in the pediatric operating room112 found that formula acceptable but associated with a marginally greater reintubation rate than with the Khine formula (ID [mm]=[age in years/4] + 3).Treatment RecommendationsIf a cuffed tracheal tube is used in infants ≥3.5 kg and <1 year of age, it is reasonable to use a tube with an ID of 3.0 mm. If a cuffed tracheal tube is used in children between 1 and 2 years of age, it is reasonable to use a tube with an ID of 3.5 mm.After the age of 2, it is reasonable to estimate the cuffed tracheal tube size with the formula ID (mm)=(age in years/4) + 3.5. If the tracheal tube meets resistance during insertion, a tube with an ID 0.5 mm smaller should be used. If there is no leak around the tube with the cuff deflated, reintubation with a tube ID 0.5 mm smaller may be beneficial when the patient is stable.Knowledge GapsAre the formulas for estimation of tracheal tube size that are used for elective intubation in the operating room setting applicable during resuscitation? Is there an upper age limit for the validity of the formula to estimate tube size? Are length-based formulas more accurate compared with age- or weight-based formulas for estimating tracheal tube size in infants and children?Bag-Mask Ventilation Versus IntubationPeds-008Consensus on ScienceOne LOE 1 study116 compared paramedic out-of-hospital BMV with intubation for children with cardiac arrest, respiratory arrest, or respiratory failure in an EMS system with short transport intervals and found equivalent rates of survival to hospital discharge and neurologic outcome. One LOE 1 systematic review that included this study117 also reached the same conclusion.One LOE 2 study of pediatric trauma patients118 observed that out-of-hospital intubation is associated with a higher risk of mortality and postdischarge neurologic impairment compared with in-ho
Referência(s)