Anti-Arrhythmic Drugs for Cardiac Arrest- Pediatrics
Atkins DL, Aickin RP, Bingham R, Couper K, Couto TB, de Caen AR, Guerguerian A-M, Hazinski MF, Lavonas E, Meaney PA, Nadkarni VM, Ng KC, Nuthall GA, Ohshimo S, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Shimizu NS, Tijssen JA, Van de Voorde P, Maconochie IK. Antiarrhythmic Drugs for Cardiac Arrest in Adults and Children Consensus on Science and Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric Life Support Task Force 2018 May 30. Available from http://ilcor.org
Anti-Arrhythmic Drugs in Cardiac Arrest PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs, and Time Frame)
Population: Patients of all ages (neonates, children and adolescents < 18) in any setting (in-hospital or out-of-hospital) with cardiac arrest and a shockable rhythm at any time during cardiopulmonary resuscitation (CPR) or immediately after Return of Spontaneous Circulation (ROSC).
Intervention: Administration (intravenous or intra-osseous) of an antiarrhythmic drug during CPR and immediately (within 1 hour) after ROSC.
Comparators: Another anti-arrhythmic drug or placebo or no drug during CPR or immediately after ROSC.
Outcome: Survival to hospital discharge with good neurologic outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome. For antiarrhythmic drugs after ROSC – re-arrest was included as an important outcome.
Study Design: Randomised controlled trials (RCTs) and non-randomised studies (non-randomised controlled trials, interrupted time-series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Animal studies were excluded. Unpublished studies (e.g., conference abstracts, trial protocols) were excluded.
Timeframe: All years and all languages were included as long as there was an English abstract; The literature search was updated to August 15, 2017
For the critical outcome of survival to hospital discharge, one observational study with 302 patients found no difference in effect for lidocaine compared with amiodarone (25% versus 17%; P=NS; RR 1.50; 95% CI 0.90-2.52), 84 survivors /1000 treated (range less than 17 to greater than 256, NS effect) . (Valdes, 2014, 381)
For the important outcome of ROSC, one observational study with 302 patients showed significant increase in ROSC for the lidocaine group compared with amiodarone (64% versus 44%; P=0.004; RR 1.46; 95% CI 1.13-1.88), 202 more/1000treated (range 57-386 ,ore, NNT = 5 (95%CI 3-18) . (Valdes, 2014, 381)
We suggest amiodarone or lidocaine be used in the treatment of pediatric shock-refractory VF/pVT (weak recommendation, very low quality evidence).
Values and Preferences
We place a higher value on the use of pediatric registry data over the adult literature. While there are several adult RCTs comparing lidocaine, amiodarone and placebo, the populations studied are substantially different from both pediatric (pre-pubertal) or adolescent populations. The adult studies generally included patients > 50 years. The Task Force felt that the causes of cardiac arrest in adults, most commonly myocardial ischemia, are sufficiently different from the causes in children that extrapolation from these data was not valid. Although the causes of in-hospital and out- of hospital cardiac arrest in children may differ, we feel that extrapolation to pediatric out-of-hospital cardiac arrest is reasonable.
The Task Force has serious concerns about the quality of the data. The available study included data collected before 2005. The practice guidelines before 2005 did not emphasize the quality of CPR as an important variable that influences outcomes.
- Randomized studies on anti-arrhythmic use during both out-of-hospital and in-hospital pediatric cardiac arrest are lacking. Ideally, outcomes should include survival to hospital discharge, neurodevelopmental outcomes and patient centered outcomes.
- Optimal timing of drug delivery with respect to defibrillation or epinephrine is unknown.
- Anti-arrhythmic effectiveness and adverse events with respect to the cause of cardiac arrest (i.e. channelopathy vs structural vs ischemic), primary versus secondary VF/pVT and developmental age is unknown.