Editorials
was also seen, that is, the more prolonged the cooling time, the higher the risk for infections. This meta-analysis was well performed from the methodological perspective but limitations of the original trials are important as the authors recognized in the article: "the risk of bias in the included studies was high because information on the method of randomization and definitions of infections lacked in most cases, and assessment of infections was not blinded." Also concerning is the fact that the authors had to exclude 31 randomized trials with 4,004 patients because they did not report any quantitative data on infection complications! Hence, underreporting of infection complications is very likely. This finding in combination with the authors' results indicating higher risk of pneumonia and sepsis is definitely relevant because they suggest that we still do not know the actual risk of infection, which could be even higher than the one found in this new meta-analysis. Is there a biological rationale for the increased risk for infections? Yes, hypothermia alters the cytokine dynamics, reducing proinflammatory cytokines and inhibiting leukocyte migration and phagocytosis, all of which could be involved in the higher propensity for infections (8). Whether prophylactic antibiotics should be used, or even if they would have any efficacy in the setting of substantial vasoconstriction and altered pharmacokinetic and pharmacodynamic properties during hypothermia, remains to be defined in future studies. The findings from the meta-analysis by Ceurts et al (7) are pertinent for both clinicians and researchers: they establish
that hypothermia is in fact associated with a significant higher risk of pneumonia and sepsis (clinical awareness) and that all clinical trials on therapeutic hypothermia must perform the systematic collection of infection data (research awareness) as part of their design, case report form, and statistical plan to report this indispensable safety analysis.
REFERENCES 1. Holzer M: Targeted temperature management for oomatose survivors ot cardiao arrest. N EngI J Med 2010; 363:1256-1264 2. Hypothermia atter Cardiao Arrest Study Group: Mild therapeutio hypothermia to improve the neurologic outcome atter cardiac arrest. N EngI J Med 2002; 346:549-556 3. Bernard SA, Gray TW, Buist MD, et al: Treatment ot comatose survivors ot out-of-hospital cardiac arrest with induced hypothermia. N EngI J Med 2002; 346:557-563 4. Kammersgaard LP, J0rgensen HS, Rungby JA, et al: Admission body temperature predicts long-term mortality atter acute stroke: The Copenhagen Stroke Study. Stroke 2002; 33:1759-1762 5. Kim F, Olsutka M, Longstreth WT Jr, et al: Pilot randomized olinical trial ot prehospital induction of mild hypothermia in out-ot-hospital cardiac arrest patients vi/ith a rapid infusion of 4 degrees G normal saline. Circulation 2007; 115:3064-3070 6. Nielsen N, Hovdenes J, Nilsson F, et al; Hypothermia Netv^íork: Gutcome, timing and adverse events in therapeutic hypothermia atter out-ot-hospital cardiac arrest. Acta Anaesthesiol Scand 2009; 53:926-934 7 Geurts M, Maoleod MR, Kollmar R, et al: Therapeutic Hypothermia and the Risk of Infection: A Systematic Review and Meta-Analysis. Crit Care Med 2014; 42:231-242 8. Polderman KH: Mechanisms of action, physiological ettects, and complications of hypothermia. Crit Care Med 2009; 37:S186-S202
Training Pédiatrie Rapid Response Teams: The Next Layer?* Dantin Jera my Roddy, MD Division of Critical Care Medicine Children's National Medical Center Washington, DC David C. Stockwell, MD, MBA Pédiatrie Intensive Care Unit Children's National Medical Center; and Department of Pediatrics George Washington University, School of Medicine Washington, DC "See also p. 243. Key Words: cardiac arrest; cardiopulmonary resuscitation; outcomes; pédiatrie; rapid response team The authors have disclosed that they do not have any potential conflicts of interest. Gopyright © 2013 by the Society of Critical Gare Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435694.15963.ae 446
www.ccmjournal.org
I
n 1996, the Institute for Healthcare Improvement suggested implementation of rapid response teams (RRTs) as one of six recommended strategies to prevent inpatient deaths (1). This concept, initially applied to adult care, has now become the standard of practice in pédiatrie hospitals (2-4). Many pédiatrie hospitals are now striving to advance the performance of RRTs to improve early intervention and ultimately prevent pédiatrie arrests (3, 5-9). Over the past 15 years, cardiopulmonary resuscitation (CPR) effectiveness has also been studied aggressively (1012). According to 2008 data from the National Registry of Cardiopulmonary Resuscitation, survival rates as high as 33% have been seen with inpatient pédiatrie pulseless arrest. Not surprisingly, children and infants who received interventions prior to progression to arrest had a 64% survival to discharge (10). Improved RRT performance may help to bolster these needed interventions and therefore yield improved outcomes. February 2014 • Volume 42 • Number 2
Editorials
In this issue of Critical Care Medicine, Knight et al (7) investigated the effectiveness of "Composite Resuscitation Team Training" in reducing in-hospital mortality after pédiatrie cardiopulmonary arrest. Secondary outcome measures were 1) change from neurologic baseline and 2) improvement of code team performance. Using historical controls, they conducted a prospective observational study at a large academic children's hospital. During the intervention phase, all RRT members completed or participated in up to seven types of training, ranging from Basic Life Support (BLS)/Pediatric Advanced Life Support (PALS) to in situ and high-fidelity code blue simulations. RRT members were introduced to training prior to the intervention and continued training during the intervention phase.
and training of pédiatrie RRTs. All members of the RRT "participated in team-training exercises," similar to those seen in the study by Knight et al (7). Clinical outcomes were significant for decreased number of non-ICU cardiac arrests (relative risk [RR] reduction 65%,p = 0.001) and decreased deaths (RR reduction 56%, p = 0.005). The major difference seen when comparing these studies was the lack of simulation in the training process reported by Mistry et al (3). These two efforts are an interesting comparison of similar interventions with similar results, but what was the most impactful component? It is also not clear if results decay over time and repeat interventions may be needed. Focusing resources in the most effective way is needed to preserve improved outcomes suggested in both of these authors' work.
Their results suggest that patients with code events during the intervention phase were more likely to survive compared with historical controls (60.9% vs 40.3%). Knight et al (7) also demonstrated the intervention group had an increased odds of survival as compared with the preintervention group (odds ratio = 2.13; 95% CI, 1.06-4.36). Furthermore, there was also a propensity for the code team to adhere to the American Heart Association resuscitation guidelines during the intervention phase (35.9%) than the preintervention phase (20.8%). However, there was no significant change in neurologic morbidity when comparing preintervention with intervention change in Pédiatrie Cerebral Performance Category (0.27 vs 0.1; p = 0.37). These results are certainly laudable and deserve more indepth examination. Many questions remain however. What is it about this intervention? Were the team members just better prepared and trained to manage these situations, leading to better outcomes? Were their patients different somehow? Can we just assume that training of RRT members will suffice to improve in-hospital mortality universally? Which aspect(s) of training were most critical to improvement of survival?
Recently, regarding education and training of RRTs, Sharek et al (4) stated that "Educational interventions, in particular those covering a large number of staff (nurses, physicians, and respiratory therapists) who work throughout a hospital, are often ineftictive and rarely attain such dramatic effects on outcomes". The challenge is now to determine if the application of BLS/PALS, proficient use of intraosseous drill, proper use of a defibrillator, or high-fidelity simulation as single interventions or applied as a partial or complete group would achieve similar survival outcomes. Also, what is the frequency of repeat interventions that will preserve these outcomes? Knight et al (7) have provided evidence to support that better training of RRTs leads to reduced mortality and morbidity after a child has a cardiac arrest. Determining where to focus these efforts and to whom and which components are most important will improve our understanding of how to best prepare RRTs and code teams for optimal performance.
There are several factors that could have affected their outcomes. Improved survival could be at least partially impacted by a disproportionate number of cardiac patients during the intervention phase. There is evidence supporting better survival outcomes in cardiac versus noncardiac patients who required emergency application of extraeorporeal CPR (13,14). Several authors have evaluated CPR and its effectiveness in preserving survivability to discharge (10-12). Recurrent themes in these studies are quality of CPR (appropriate rate and depth, limited interruptions), initial documented rhythm, and duration of CPR. The results seen by BCnight et al (7) could be a representation of improvement in quality of CPR; however, quality of CPR was not measured. Measurement of CPR quality would have provided insight into which component of the intervention was most successful in improving outcomes. This is one of the first studies to demonstrate that ongoing RRT training can significantly impact the survivability associated with pédiatrie cardiac arrests. Still the question remains, is it the team training, broader knowledge of PALS by the RRT respondents, better CPR application to the decompensating patient, or the entire intervention that made the difference? Mistry et al (3) assessed the effectiveness of implementation
1. Berwick DM, Calkins DR, McCannon CJ, ef al: The 100,000 lives campaign: Sefting a goal and a deadline for improving health care quality. JAMA 2006; 295:324-327 2. Kotsakis A, Lobos AT, Parshuram C, et al; Ontario Pédiatrie Critical Care Response Team Collaborative: Implementation of a mulficenfer rapid response system in pédiatrie academic hospifals is effecfive. Pediatries 2011 ; 1 28:72-78 3. Mistry KP, Turi J, Hueckel R, ef al: Pédiatrie rapid response teams in the academic medical center. Clin Ped Emerg Med 2006; 7:241-247 4. Sharek PJ, Parasf LM, Leong K, ef al: Effect of a rapid response feam on hospifal-wide mortality and code rates outside the ICU in a children's hospital. JAMA 2007; 298:2267-2274 5. Andreatta P, Saxton E, Thompson M, et al: Simulation-based mock codes significantly correlafe wifh improved pédiatrie pafienf cardiopulmonary arrest survival rates. Pediatr Crit Care Med 2011; 12:33-38 6. Cheng A, Hunt EA, Donoghue A, ef al; EXPRESS Investigators: Examining pédiatrie resuscifafion education using simulation and scripfed debriefing: A mulficenfer randomized trial. JAMA Pediatr 2013; 167:528-536 7. Knighf LJ, Gabharf JM, Earnesf KS, ef al: Improving Code Team Performance and Survival Oufcomes: Implemenfafion of Pediafric Resuscitation Team Training. Crit Care Med 2014; 42:243-251 8. TurekJW, Andersen ND, Lawson DS, ef al: Outcomes before and after implemenfafion of a pediafric rapid-response exfracorporeal membrane oxygenafion program. Ann Thorac Surg 2013; 95:2140-2146 9. van Schaik SM, Plant J, Diane S, ef al: Inferprofessional feam fraining in pediafric resuscifation: A low-cost, in sifu simulation program fhaf
Critical Care Medicine
REFERENCES
wvvw.ccmjcurnal.org
447
Ediforials enhances self-efficacy among participants, din Pediatr (Phiia) 2011 ; 50:807-815 10, Berg MD, Schexnayder SM, Chameides L, et al: Part 13: Pédiatrie basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circuiation 2010; 1 22:S862-S875 11, Nadkarni VM, Larkin GL, Peberdy MA, et al; National Registry of Cardiopulmonary Resuscitation Investigators: First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults, JAMA 2006; 295:50-57
12, Slonim AD, Patel KM, Ruttimann U E, et al: Cardiopulmonary resuscitation in pédiatrie intensive care units, Crit Care Med 1997; 25:1951-1955 13, Alsoufi B, Al-Radi CO, Nazer Rl, et al: Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pédiatrie patients with refractory cardiac arrest, J Thorac Cardiovasc Surg 2007; 134:952-959,e2 14, Morris MC, Wernovsky G, Nadkarni VM: Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pédiatrie cardiac arrest. Pediatr Crit Care Med 2004; 5:440-446
Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome: When Should We Turn Up the Pressure?* Ewan C. Goiigher, MD Interdepartmental Division of Critical Care Medicine University of Toronto; and Division of Respirology Department of Medicine University Health Network Toronto, ON, Canada JesúsViiiar, MD, PhD Keenan Research Center Li Ka Shing Knowledge Institute of St. Michael's Hospital Toronto, ON, Canada CIBER de Enfermedades Respiratorias Instituto de Salud Carlos III Madrid, Spain; and Research Unit Hospital Universitario Dr. Negn'n Las Palmas de Gran Canaria, Spain
*See also p. 252. Key Words: acute respiratory distress syndrome; lung recruitment; positive end-expiratory pressure Dr. Goiigher received grant support from Canadian Institutes of Health Research Fellowship. His institution received grant support from PSI Foundation (grant supporting research on VIDD), Dr, Slutsky has a grant from Canadian Institutes for Health Research (CIHR) to study Ventilator-Induced Lung Injury; consults for Maquet Medical which markets ventilators; served as an author on references (4, 5, 12) and could be viewed as having an academic conflict of interest in relation to PEEP; and received support for article research from CIHR, His institution received grant support from the CIHR, Dr, Villar has disclosed that he does not have any potential conflicts of interest. Copyright ® 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435685.00716.48
448
www,ccnnjcurnal,org
ArthurS.Siutsky, MD Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, ON, Canada; and Keenan Research Center Li Ka Shing Knowledge Institute of St, Michael's Hospital Toronto, ON, Canada
r • ;he use of positive end-expiratory pressure (PEEP) in I patients with the acute respiratory distress syndrome (ARDS) was first described by Ashbaugh et al ( 1 ) in their classical article identifying this syndrome. Allfivepatients treated with PEEP levels of 5-10 cm H,O demonstrated an increase in oxygénation. Ashbaugh et al ( 1 ) also noted an "apparent increase in survival" with the use of PEEP, but given the extremely small sample, they felt that this finding would have to be confirmed in a larger study. Three large randomized trials of higher versus lower PEEP strategies (2-4) together with a subsequent individual patient meta-analysis (5) suggest that, in general, patients with more severe ARDS, as assessed by the Pao^/Eio, (P/F) ratio, have better outcomes when higher PEEP levels are applied. However, because no single PEEP titration strategy has been shown to improve survival, the fundamental question of how to set PEEP in any individual patient remains unanswered and continues to be a vexing challenge for clinicians. Whereas PEEP was previously titrated to optimize oxygénation (6) or oxygen delivery (7), current thinking focuses on the application of PEEP to mitigate ventilator-induced lung injury (VILI) (8). Under this paradigm, PEEP is titrated to minimize the competing determinants of VILI: alveolar hyperinflation (volutrauma) and cyclic recruitment during tidal ventilation (atelectrauma). Because patients with ARDS exhibit wide heterogeneity in lung recruitability (9, 10), increasing PEEP to reduce atelectrauma without increasing volutrauma is a difficult balancing act. By inference, PEEP should be titrated in February 2014 • Volume 42 • Number 2
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
was also seen, that is, the more prolonged the cooling time, the higher the risk for infections. This meta-analysis was well performed from the methodological perspective but limitations of the original trials are important as the authors recognized in the article: "the risk of bias in the included studies was high because information on the method of randomization and definitions of infections lacked in most cases, and assessment of infections was not blinded." Also concerning is the fact that the authors had to exclude 31 randomized trials with 4,004 patients because they did not report any quantitative data on infection complications! Hence, underreporting of infection complications is very likely. This finding in combination with the authors' results indicating higher risk of pneumonia and sepsis is definitely relevant because they suggest that we still do not know the actual risk of infection, which could be even higher than the one found in this new meta-analysis. Is there a biological rationale for the increased risk for infections? Yes, hypothermia alters the cytokine dynamics, reducing proinflammatory cytokines and inhibiting leukocyte migration and phagocytosis, all of which could be involved in the higher propensity for infections (8). Whether prophylactic antibiotics should be used, or even if they would have any efficacy in the setting of substantial vasoconstriction and altered pharmacokinetic and pharmacodynamic properties during hypothermia, remains to be defined in future studies. The findings from the meta-analysis by Ceurts et al (7) are pertinent for both clinicians and researchers: they establish
that hypothermia is in fact associated with a significant higher risk of pneumonia and sepsis (clinical awareness) and that all clinical trials on therapeutic hypothermia must perform the systematic collection of infection data (research awareness) as part of their design, case report form, and statistical plan to report this indispensable safety analysis.
REFERENCES 1. Holzer M: Targeted temperature management for oomatose survivors ot cardiao arrest. N EngI J Med 2010; 363:1256-1264 2. Hypothermia atter Cardiao Arrest Study Group: Mild therapeutio hypothermia to improve the neurologic outcome atter cardiac arrest. N EngI J Med 2002; 346:549-556 3. Bernard SA, Gray TW, Buist MD, et al: Treatment ot comatose survivors ot out-of-hospital cardiac arrest with induced hypothermia. N EngI J Med 2002; 346:557-563 4. Kammersgaard LP, J0rgensen HS, Rungby JA, et al: Admission body temperature predicts long-term mortality atter acute stroke: The Copenhagen Stroke Study. Stroke 2002; 33:1759-1762 5. Kim F, Olsutka M, Longstreth WT Jr, et al: Pilot randomized olinical trial ot prehospital induction of mild hypothermia in out-ot-hospital cardiac arrest patients vi/ith a rapid infusion of 4 degrees G normal saline. Circulation 2007; 115:3064-3070 6. Nielsen N, Hovdenes J, Nilsson F, et al; Hypothermia Netv^íork: Gutcome, timing and adverse events in therapeutic hypothermia atter out-ot-hospital cardiac arrest. Acta Anaesthesiol Scand 2009; 53:926-934 7 Geurts M, Maoleod MR, Kollmar R, et al: Therapeutic Hypothermia and the Risk of Infection: A Systematic Review and Meta-Analysis. Crit Care Med 2014; 42:231-242 8. Polderman KH: Mechanisms of action, physiological ettects, and complications of hypothermia. Crit Care Med 2009; 37:S186-S202
Training Pédiatrie Rapid Response Teams: The Next Layer?* Dantin Jera my Roddy, MD Division of Critical Care Medicine Children's National Medical Center Washington, DC David C. Stockwell, MD, MBA Pédiatrie Intensive Care Unit Children's National Medical Center; and Department of Pediatrics George Washington University, School of Medicine Washington, DC "See also p. 243. Key Words: cardiac arrest; cardiopulmonary resuscitation; outcomes; pédiatrie; rapid response team The authors have disclosed that they do not have any potential conflicts of interest. Gopyright © 2013 by the Society of Critical Gare Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435694.15963.ae 446
www.ccmjournal.org
I
n 1996, the Institute for Healthcare Improvement suggested implementation of rapid response teams (RRTs) as one of six recommended strategies to prevent inpatient deaths (1). This concept, initially applied to adult care, has now become the standard of practice in pédiatrie hospitals (2-4). Many pédiatrie hospitals are now striving to advance the performance of RRTs to improve early intervention and ultimately prevent pédiatrie arrests (3, 5-9). Over the past 15 years, cardiopulmonary resuscitation (CPR) effectiveness has also been studied aggressively (1012). According to 2008 data from the National Registry of Cardiopulmonary Resuscitation, survival rates as high as 33% have been seen with inpatient pédiatrie pulseless arrest. Not surprisingly, children and infants who received interventions prior to progression to arrest had a 64% survival to discharge (10). Improved RRT performance may help to bolster these needed interventions and therefore yield improved outcomes. February 2014 • Volume 42 • Number 2
Editorials
In this issue of Critical Care Medicine, Knight et al (7) investigated the effectiveness of "Composite Resuscitation Team Training" in reducing in-hospital mortality after pédiatrie cardiopulmonary arrest. Secondary outcome measures were 1) change from neurologic baseline and 2) improvement of code team performance. Using historical controls, they conducted a prospective observational study at a large academic children's hospital. During the intervention phase, all RRT members completed or participated in up to seven types of training, ranging from Basic Life Support (BLS)/Pediatric Advanced Life Support (PALS) to in situ and high-fidelity code blue simulations. RRT members were introduced to training prior to the intervention and continued training during the intervention phase.
and training of pédiatrie RRTs. All members of the RRT "participated in team-training exercises," similar to those seen in the study by Knight et al (7). Clinical outcomes were significant for decreased number of non-ICU cardiac arrests (relative risk [RR] reduction 65%,p = 0.001) and decreased deaths (RR reduction 56%, p = 0.005). The major difference seen when comparing these studies was the lack of simulation in the training process reported by Mistry et al (3). These two efforts are an interesting comparison of similar interventions with similar results, but what was the most impactful component? It is also not clear if results decay over time and repeat interventions may be needed. Focusing resources in the most effective way is needed to preserve improved outcomes suggested in both of these authors' work.
Their results suggest that patients with code events during the intervention phase were more likely to survive compared with historical controls (60.9% vs 40.3%). Knight et al (7) also demonstrated the intervention group had an increased odds of survival as compared with the preintervention group (odds ratio = 2.13; 95% CI, 1.06-4.36). Furthermore, there was also a propensity for the code team to adhere to the American Heart Association resuscitation guidelines during the intervention phase (35.9%) than the preintervention phase (20.8%). However, there was no significant change in neurologic morbidity when comparing preintervention with intervention change in Pédiatrie Cerebral Performance Category (0.27 vs 0.1; p = 0.37). These results are certainly laudable and deserve more indepth examination. Many questions remain however. What is it about this intervention? Were the team members just better prepared and trained to manage these situations, leading to better outcomes? Were their patients different somehow? Can we just assume that training of RRT members will suffice to improve in-hospital mortality universally? Which aspect(s) of training were most critical to improvement of survival?
Recently, regarding education and training of RRTs, Sharek et al (4) stated that "Educational interventions, in particular those covering a large number of staff (nurses, physicians, and respiratory therapists) who work throughout a hospital, are often ineftictive and rarely attain such dramatic effects on outcomes". The challenge is now to determine if the application of BLS/PALS, proficient use of intraosseous drill, proper use of a defibrillator, or high-fidelity simulation as single interventions or applied as a partial or complete group would achieve similar survival outcomes. Also, what is the frequency of repeat interventions that will preserve these outcomes? Knight et al (7) have provided evidence to support that better training of RRTs leads to reduced mortality and morbidity after a child has a cardiac arrest. Determining where to focus these efforts and to whom and which components are most important will improve our understanding of how to best prepare RRTs and code teams for optimal performance.
There are several factors that could have affected their outcomes. Improved survival could be at least partially impacted by a disproportionate number of cardiac patients during the intervention phase. There is evidence supporting better survival outcomes in cardiac versus noncardiac patients who required emergency application of extraeorporeal CPR (13,14). Several authors have evaluated CPR and its effectiveness in preserving survivability to discharge (10-12). Recurrent themes in these studies are quality of CPR (appropriate rate and depth, limited interruptions), initial documented rhythm, and duration of CPR. The results seen by BCnight et al (7) could be a representation of improvement in quality of CPR; however, quality of CPR was not measured. Measurement of CPR quality would have provided insight into which component of the intervention was most successful in improving outcomes. This is one of the first studies to demonstrate that ongoing RRT training can significantly impact the survivability associated with pédiatrie cardiac arrests. Still the question remains, is it the team training, broader knowledge of PALS by the RRT respondents, better CPR application to the decompensating patient, or the entire intervention that made the difference? Mistry et al (3) assessed the effectiveness of implementation
1. Berwick DM, Calkins DR, McCannon CJ, ef al: The 100,000 lives campaign: Sefting a goal and a deadline for improving health care quality. JAMA 2006; 295:324-327 2. Kotsakis A, Lobos AT, Parshuram C, et al; Ontario Pédiatrie Critical Care Response Team Collaborative: Implementation of a mulficenfer rapid response system in pédiatrie academic hospifals is effecfive. Pediatries 2011 ; 1 28:72-78 3. Mistry KP, Turi J, Hueckel R, ef al: Pédiatrie rapid response teams in the academic medical center. Clin Ped Emerg Med 2006; 7:241-247 4. Sharek PJ, Parasf LM, Leong K, ef al: Effect of a rapid response feam on hospifal-wide mortality and code rates outside the ICU in a children's hospital. JAMA 2007; 298:2267-2274 5. Andreatta P, Saxton E, Thompson M, et al: Simulation-based mock codes significantly correlafe wifh improved pédiatrie pafienf cardiopulmonary arrest survival rates. Pediatr Crit Care Med 2011; 12:33-38 6. Cheng A, Hunt EA, Donoghue A, ef al; EXPRESS Investigators: Examining pédiatrie resuscifafion education using simulation and scripfed debriefing: A mulficenfer randomized trial. JAMA Pediatr 2013; 167:528-536 7. Knighf LJ, Gabharf JM, Earnesf KS, ef al: Improving Code Team Performance and Survival Oufcomes: Implemenfafion of Pediafric Resuscitation Team Training. Crit Care Med 2014; 42:243-251 8. TurekJW, Andersen ND, Lawson DS, ef al: Outcomes before and after implemenfafion of a pediafric rapid-response exfracorporeal membrane oxygenafion program. Ann Thorac Surg 2013; 95:2140-2146 9. van Schaik SM, Plant J, Diane S, ef al: Inferprofessional feam fraining in pediafric resuscifation: A low-cost, in sifu simulation program fhaf
Critical Care Medicine
REFERENCES
wvvw.ccmjcurnal.org
447
Ediforials enhances self-efficacy among participants, din Pediatr (Phiia) 2011 ; 50:807-815 10, Berg MD, Schexnayder SM, Chameides L, et al: Part 13: Pédiatrie basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circuiation 2010; 1 22:S862-S875 11, Nadkarni VM, Larkin GL, Peberdy MA, et al; National Registry of Cardiopulmonary Resuscitation Investigators: First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults, JAMA 2006; 295:50-57
12, Slonim AD, Patel KM, Ruttimann U E, et al: Cardiopulmonary resuscitation in pédiatrie intensive care units, Crit Care Med 1997; 25:1951-1955 13, Alsoufi B, Al-Radi CO, Nazer Rl, et al: Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pédiatrie patients with refractory cardiac arrest, J Thorac Cardiovasc Surg 2007; 134:952-959,e2 14, Morris MC, Wernovsky G, Nadkarni VM: Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pédiatrie cardiac arrest. Pediatr Crit Care Med 2004; 5:440-446
Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome: When Should We Turn Up the Pressure?* Ewan C. Goiigher, MD Interdepartmental Division of Critical Care Medicine University of Toronto; and Division of Respirology Department of Medicine University Health Network Toronto, ON, Canada JesúsViiiar, MD, PhD Keenan Research Center Li Ka Shing Knowledge Institute of St. Michael's Hospital Toronto, ON, Canada CIBER de Enfermedades Respiratorias Instituto de Salud Carlos III Madrid, Spain; and Research Unit Hospital Universitario Dr. Negn'n Las Palmas de Gran Canaria, Spain
*See also p. 252. Key Words: acute respiratory distress syndrome; lung recruitment; positive end-expiratory pressure Dr. Goiigher received grant support from Canadian Institutes of Health Research Fellowship. His institution received grant support from PSI Foundation (grant supporting research on VIDD), Dr, Slutsky has a grant from Canadian Institutes for Health Research (CIHR) to study Ventilator-Induced Lung Injury; consults for Maquet Medical which markets ventilators; served as an author on references (4, 5, 12) and could be viewed as having an academic conflict of interest in relation to PEEP; and received support for article research from CIHR, His institution received grant support from the CIHR, Dr, Villar has disclosed that he does not have any potential conflicts of interest. Copyright ® 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01 .ccm.0000435685.00716.48
448
www,ccnnjcurnal,org
ArthurS.Siutsky, MD Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, ON, Canada; and Keenan Research Center Li Ka Shing Knowledge Institute of St, Michael's Hospital Toronto, ON, Canada
r • ;he use of positive end-expiratory pressure (PEEP) in I patients with the acute respiratory distress syndrome (ARDS) was first described by Ashbaugh et al ( 1 ) in their classical article identifying this syndrome. Allfivepatients treated with PEEP levels of 5-10 cm H,O demonstrated an increase in oxygénation. Ashbaugh et al ( 1 ) also noted an "apparent increase in survival" with the use of PEEP, but given the extremely small sample, they felt that this finding would have to be confirmed in a larger study. Three large randomized trials of higher versus lower PEEP strategies (2-4) together with a subsequent individual patient meta-analysis (5) suggest that, in general, patients with more severe ARDS, as assessed by the Pao^/Eio, (P/F) ratio, have better outcomes when higher PEEP levels are applied. However, because no single PEEP titration strategy has been shown to improve survival, the fundamental question of how to set PEEP in any individual patient remains unanswered and continues to be a vexing challenge for clinicians. Whereas PEEP was previously titrated to optimize oxygénation (6) or oxygen delivery (7), current thinking focuses on the application of PEEP to mitigate ventilator-induced lung injury (VILI) (8). Under this paradigm, PEEP is titrated to minimize the competing determinants of VILI: alveolar hyperinflation (volutrauma) and cyclic recruitment during tidal ventilation (atelectrauma). Because patients with ARDS exhibit wide heterogeneity in lung recruitability (9, 10), increasing PEEP to reduce atelectrauma without increasing volutrauma is a difficult balancing act. By inference, PEEP should be titrated in February 2014 • Volume 42 • Number 2
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
