Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Dallas 2015 (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”. Dallas 2015 C2015 PICO Dallas 2015 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 Dallas 2015 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 Dallas 2015 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 Dallas 2015 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) Dallas 2015 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) Dallas 2015 Dallas 2015 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). Dallas 2015 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) Dallas 2015 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