Pediatric resuscitation pharmacology

Abstract

The goal of resuscitation pharmacology is to restart the heart as quickly as possible while preserving vital organ function during chest compression. Unfortunately, the application of advanced life support to pediatric cardiac arrest patients is often unsuccessful. The goal of this paper is to review the scientific rationale and educational considerations used to derive the guidelines for medication use in the pediatric patient during CPR. The first step in drug delivery during CPR is to achieve vascular access. The endotracheal route and intraosseous route may be used, although the former is not reliable. To maximize endotracheal drug effect, a larger dose should be instilled into the airway as deeply as possible. Any vascular access, including intraosseous, is preferable to endotracheal drug administration. Although other alpha-adrenergic agents are theoretically superior, epinephrine remains the drug of choice in pediatric resuscitation. The previously recommended dose, however, may be inadequate; a dose 10 to 20 times larger (100-200 micrograms/kg) should be considered, particularly if the standard dose is ineffective. Lacking convincing data, the indications and dose for calcium are unchanged. Similarly, there are no data advocating a change in the indications or dose for lidocaine, bretylium, or atropine. The treatment of arrest-induced acidosis remains controversial. The mainstay of therapy consists of efforts to maximize oxygenation and tissue perfusion. Bicarbonate is not a first-line drug; its use should be considered when the patient fails to respond to advanced life support efforts, including the administration of high-dose epinephrine. Bicarbonate may be helpful in the postresuscitation setting, but its use should not supplant efforts to maximize tissue perfusion. Adenosine is an effective and generally safe medication for the treatment of supraventricular tachycardia in infants and children. Therefore, its indications, dose, and toxicities should be included in the new guidelines. Finally, a summary of research initiatives are included, including a call for the development of a multi-institutional pediatric clinical resuscitation research group. Large numbers of patients must be enrolled in a standardized manner to better evaluate the benefits and adverse effects of various therapies. This includes the use of high-dose epinephrine, calcium, bicarbonate, and other buffer agents such as Carbicarb and THAM. Animal models simulating the etiology and pathophysiology of pediatric arrest also are needed. In both clinical and animal studies, neurologic outcome and long-term survival should be assessed rather than simply the rate of restoration of spontaneous circulation.