Don’t use outdated approaches for critically ill infants and children
New guidelines for pediatric advanced life support provide fresh options
Do you know if high-dose epinephrine is recommended for children in pulseless arrest? Would you use the intraosseous route to obtain vascular access in an 8-year-old? Should you use an adult-size or infant-size resuscitation bag in a newborn? If you’re unsure of these answers, you’ll need to revamp your practice based on new guidelines for pediatric advanced life support (PALS) from the Dallas-based American Heart Association (AHA).
Attend a PALS course as soon as the new materials are available in your area, urges Teresa Ostler, RN, ED educator and PALS coordinator at Primary Children’s Medical Center in Salt Lake City. "There are so many exciting changes in the PALS program." The AHA’s new PALS guidelines are now the standard for resuscitation of critically ill infants and children around the world, emphasizes Ostler. "These are the standards of care that our smallest patients deserve, that all professional nurses should strive to attain, and that our communities will expect from us."
All nurses who care for children at risk for respiratory failure, shock, cardiac rhythm disturbances, and/or cardiopulmonary arrest must become familiar with the new PALS guidelines, urges Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA.
Guidelines published by the AHA are generally considered to be "standard of care," notes Barbara Weintraub, RN, MPH, MSN, pediatric critical care nurse practitioner at Northwest Community Hospital in Arlington Heights, IL. "Most lawsuits involving nurses concern a failure on the part of the nurse to meet the standard of care," she warns. "Many potential lawsuits can be avoided by ED nurses familiarizing themselves with the new PALS guidelines."
Here are some of the key practice changes recommended by the guidelines:
• Infant resuscitation bags are no longer recommended for infants or children. Use pediatric- and adult-sized resuscitation bags instead, says Wolff . "The minimum recommended volume for resuscitation bags is 450 mL-500 mL," she adds. "The neonatal-size ventilation bag delivers only 250 mL." This volume might be inadequate to provide effective tidal volumes in term newborns and infants, Wolff explains. "Regardless of the size of the bag used, visual chest rise should be used to guide the force of bag compression."
• Endotracheal suctioning might not be necessary in the apparently vigorous infant with meconium-stained fluid. Perform direct endotracheal suctioning, using the endotracheal tube as a suction catheter, only if the infant is not moving and crying vigorously, or shows other signs of respiratory depression, recommends Weintraub.
• The use of automatic external defibrillators (AEDs) has expanded. Use of AEDs has been expanded for use in children 8 years and older, says Wolff. "It has been found that the incidence of defibrillation, while still relatively rare in children, is actually higher than once believed."
It has been extrapolated from the adult data that fewer minutes to defibrillation will increase the survival rates of children with ventricular fibrillation, Wolff explains.
• The use of the intraosseous route as an alternate for vascular access in children with shock has been expanded. You can use intraosseous access with any age patient if vascular access is not readily available and cardiopulmonary arrest or decompensated shock is present, says Weintraub. "This was previously recommended only in children 6 years of age and under."
The age range was extended because of reports of successful use of intraosseous access in patients older than 6 years, Wolff explains. "Although it may be more difficult to obtain intraosseous access in older children because of the bone thickness, this route should be considered a viable alternative when vascular access cannot be rapidly achieved."
Peripheral vascular access can be difficult in children with shock due to increased peripheral vascular resistance, says Wolff. "Rapid access to the circulatory system is critical to effective treatment of children of all ages with shock," she says.
• Use the method of "two hands encircling the chest" to do chest compressions in newborns and infants. Use this method instead of the traditional technique of two fingers on the chest, says Weintraub. "It has been found to provide greater effective cardiac output."
• The use of hyperventilation is no longer recommended to protect the brain. It has been found that hyperventilation can actually lead to decreased brain perfusion, says Wolff.
• There are new recommendations for post-resuscitation care. If hypotension persists after filling pressure is optimized and adequate fluids are ensured, use dobutamine, norepinephrine, nitroprusside, or nitroglycerine, says Weintraub. "High-dose, single-agent dopamine should be avoided." Don’t actively rewarm hemodynamically stable children who spontaneously develop a mild degree of hypothermia, Weintraub advises. "Mild hypothermia in the immediate post-resuscitation time frame may improve neurologic outcome and is likely to be well-tolerated," she says.
• Amiodarone has been added to treat superventricular tachycardia, ventricular tachycardia (VT), and ventricular fibrillation (VF). Amiodarone has been found to be effective in patients who are refractory despite three shocks, says Wolff. "Much of the data available on the use of amiodarone are in adult patients. This information has been extrapolated for use in pediatric patients." Amiodorone now is recommended for pulseless VF/VT as an antiarrythmic before the use of lidocaine, Ostler notes.
• The use of high-dose epinephrine is de-emphasized for children with pulseless arrest. There are changes in the epinephrine doses for pulseless arrest, says Ostler. "There is a decreased emphasis on the use of 1:1000 epinephrine 0.1 mg/kg."
Wolff cautions that the use of high-dose epinephrine can lead to several adverse effects, including increased myocardial work load, hyperadrenergic state, hypertension, and myocardial tissue damage.
High-dose epinephrine may be considered for second and subsequent doses of epinephrine in refractory pediatric arrest, advises Weintraub. "High-dose epinephrine does not appear to offer routine benefit, but may be acceptable. Therefore, high-dose epinephrine is not automatically given, but it may be considered."
• Care of family members is emphasized. Family presence during resuscitation has been shown to have a positive impact on families, and is recommended in the guidelines, says Wolff. "When families are present at the bedside during resuscitation, a designated staff member should remain with them to provide information and support." (For more information on family presence in the resuscitation room, see ED Nursing, November 2000.)
• The PALS course format has changed. The new format includes more practice time and less traditional lecturing, says Wolff. It also has been modified to include special resuscitation situations such as drug toxicity, electrolyte emergencies, and poisoning, she adds. "There is an increased emphasis on tailoring the course to meet the individual needs of the students," Wolff says.
Resources
For more information about the new guidelines for pediatric advanced life support, contact:
• Teresa Ostler, RN, Emergency Department, Primary Children’s Medical Center, 100 N. Medical Drive, Salt Lake City, UT 84113-1100. Telephone: (801) 588-2823. Fax: (801) 588-2263. E-mail: [email protected].
• Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-5419. E-mail: [email protected].
• Michele Wolff, RN, MSN, CCRN, Saddleback College, 28000 Marguerite Parkway, Mission Viejo, CA 92692. Telephone: (949) 582-4222. Fax: (714) 536-6269. E-mail: [email protected].
The Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care include a chapter on pediatric advanced life support. The guidelines were published in the Aug. 22, 2000, issue of Circulation, the official journal of the American Heart Association. Reprints are available for $20 plus $7 shipping and handling. To order, contact:
• Channing L. Bete Co., 200 State Road, S. Deerfield, MA 01373-0200. Telephone: (800) 611-6083 or (413) 665 7611. Fax: (800) 499-6464 or (413) 665 2671. E-mail: [email protected]. Web: www.channingbete.com.
Key changes are outlined in the AHA Web site (www.cpr-ecc.americanheart.org). Click on "What’s New." The Fall 2000 issue of Currents contains a 28-page summary of the new guidelines. Individual copies are available for $5 including shipping and handling. To order a copy, contact:
• Pro Education International, 27500 I-45 N., Suite 124, Spring, TX 77386. Telephone: (888) 999-4210 or (281) 419-8596. Fax: (281) 419-8238. E-mail: [email protected].
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