Evidence update
Worksheet Title: PLS 4160.07 Intra CA Monitoring Echocardiography POCUS
Worksheet author(s): Dr. Andrea Christoff, Jimena del Castille, Alexis Topjian, Dr Barney Scholefield
Task Force: Pediatric Life Support Task Force
Date Submitted to SAC rep for peer review and approval: Oct 10 2024
SAC rep: Laurie Morrison
PICOST / Research Question:
Population: Infants & Children in any setting (in-hospital or out-of-hospital) with cardiac arrest
Intervention: the presence of variables -images, cut-off values or trends- during CPR (intra-arrest) that can provide physiologic feedback to guide resuscitation efforts, namely:
Echocardiography / Point of care cardiac ultrasound
Comparators: the absence of such factors -images, cut-off values or trends.
Outcomes: Any clinical outcome.
Study Designs: STEP 1: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) that concern directly the population and intervention described above are eligible for inclusion. If it is anticipated that there will be insufficient studies from which to draw a conclusion, case series may be included in the initial search. The minimum number of cases for a case series to be included was set by the taskforce at 5 cases. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
STEP 2: the same study designs and/or existing systematic or scoping reviews not directly concerning the population or intervention defined above but considered informative as additional evidence for the development of the final taskforce insights.
Timeframe: For STEP 1, all languages are included, as long as there is an English abstract. We searched articles from 2020 onwards. For STEP 2, if a systematic or scoping review of high quality (as per AMSTAR 2 tool) is identified, search can be limited to beyond data and/or scope of that review.
Year of last full review:
Scoping review last searched July 2020
Kool M, Atkins DL, Van de Voorde P, Maconochie IK, Scholefield BR; PLS ILCOR Task Force. Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review. Resusc Plus. 2021 Mar 30;6:100109. doi: 10.1016/j.resplu.2021.100109. PMID: 34228034; PMCID: PMC8244529.
Current ILCOR Consensus on Science and Treatment Recommendation for this PICOS
Task Force insights
The PLS Task Force agreed that they would not accept direct extrapolation from adult studies as a result of substantial differences between adult and pediatric cardiac arrest in terms of causes, anatomy and technical matters that could affect the usefulness and accuracy of the bedside echocardiography. While the technology is widely used within the pediatric critical care, emergency and resuscitation communities, more data detailing its advantages, pitfalls and characteristics of performance are needed so its usefulness and limitations in pediatric cardiac arrest can be fully defined.
In addition, there is inadequate pediatric literature regarding its intra-arrest prognostic utility and the Task Force urges great caution until more literature is available.
Treatment Recommendations 2020
There is insufficient evidence to recommend for or against the routine use of echocardiography during a pediatric arrest. Echocardiography may be considered to identify potentially treatable causes of an arrest when appropriately skilled personnel are available, but the benefits must be carefully weighed against the known deleterious consequences of interrupting chest compressions.1,2
Current Search Strategy (for an existing PICOST) included in the attached approved PICOST |
1 or 2 or 3 |
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New Search strategy: (for a new PICOST should be outlined here as per Evidence Update Process) |
n/a |
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Database searched: eg Medline Embase Cochrane |
Medline, Embase, Central |
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Time Frame: (existing PICOST) – updated from end of last search (please specify) |
Last updated 25th July 2022 New Search July 2020 to 26th June 2024 |
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Time Frame: (new PICOST) – at the discretion of the Task Force (please specify) |
n/a |
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Date Search Completed: |
26th June 2024 |
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Search Results (Number of articles identified and number identified as relevant): |
1929 in search – 2 identified as relevant*
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*Figure created COVIDENCE
Summary of Evidence Update:
In the 2020 scoping review of intra-arrest monitoring3, 2 studies were identified describing POCUS/Echo use during pediatric cardiac arrest4,5 adding to previous case series of 14 cases in 20086
The Evidence Update in 2022 identified only 1 small case series7,8 which did not address minimizing intra-arrest compressions and focused on utility for confirming pulse checks and cardiac standstill to facilitate decision making to cease resuscitation efforts.
The Evidence Update in 2024 identified 2 studies.9,10 The first study9 was a retrospective review use of POCUS in the emergency department evaluating sensitivity and specificity for detecting left ventricular systolic dysfunction and pericardial effusion. Only 4 (0.9%) patients in cohort had a cardiac arrest. The POCUS exam details and patient outcomes were not reported. The second study10 was a small case series with 3 pediatric patients describing feasibility of using echocardiography during cardiac arrest to assess ventricular contractility and pericardial effusion.
Relevant Guidelines or Systematic Reviews
Organization (if relevant); Author; Year Published |
Guideline or systematic review |
Topic addressed or PICO(S)T |
Number of articles identified |
Key findings |
Treatment recommendations |
European Resuscitation Council Guidelines 2021: Paediatric Life Support Van de Voorde P, 2021 11 |
Guideline |
2 |
In their 2020 scoping review PLS 814 the ILCOR paediatric Taskforce warned against rapid implementation of POCUS in paediatric practice without sufficient evidence, despite its great potential and widespread acceptance. Acquisition and interpretation of images in children is more complex, especially in children with pre-existing heart disease. Furthermore, there are significant material and training costs which might be important in low-resource setting |
We suggest the use of POCUS by competent healthcare providers, when feasible, to identify reversible causes of cardiac arrest (4H/4T). POCUS may also have role in identifying the presence of perfusion, but currently this should be only in the context of research. POCUS should currently not be used for prognostication. |
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American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Topjian AA et al 2020 12 |
Guideline |
3 |
Several case series evaluated the use of bedside echocardiography to identify reversible causes of cardiac arrest, including pulmonary embolism. One prospective observational study of children (without cardiac arrest) admitted to an ICU reported good agreement of estimates of shortening fraction and inferior vena cava volume between emergency physicians using bedside limited echocardiography and cardiologists performing formal echocardiography. |
When appropriately trained personnel are available, echocardiography may be considered to identify potential treatable causes of arrest, such as pericardial tamponade and inadequate ventricular filling, but the potential benefits should be weighed against the known deleterious consequences for interrupting chest compressions. |
RCT:
Study Acronym; Author; Year Published |
Aim of Study; Study Type; Study Size (N) |
Patient Population |
Study Intervention (# patients) / Study Comparator (# patients) |
Endpoint Results (Absolute Event Rates, P value; OR or RR; & 95% CI) |
Relevant 2° Endpoint (if any); Study Limitations; Adverse Events |
No pediatric RCT |
Nonrandomized Trials, Observational Studies
Study Acronym; Author; Year Published |
Study Type/Design; Study Size (N) |
Patient Population |
Primary Endpoint and Results (include P value; OR or RR; & 95% CI) |
Summary/Conclusion Comment(s) |
Miller et al 20229 |
Retrospective review |
Pediatric N=456 POCUS exams performed 4/456 (.9%) cardiac arrest POCUS |
To describe the test characteristics for POCUS performed by pediatric emergency physicians after structured training Detection of pericardiac effusion or LVSD > 90 % sensitivity and >98% specificity |
Cardiac POCUS is feasible and can rapidly identify significant cardiac pathology. Not specific for intra-arrest use, only 4 arrest events reviewed and details and outcome not reported for cardiac arrest events |
Azzopardi et al 202310 |
Case study |
Pediatric N=3 4yo IHCA 12 yo OHCA, no ROSC 6 yo, OHCA, no ROSC |
Used to confirm cardiac standstill in 2 cases and support futility of ongoing resuscitation |
Echocardiography during resuscitation is feasible and can be used for detection of contractility and pericardial effusion |
Reviewer Comments:
There still remains little pediatric evidence examining the use of the POCUS/echocardiography during pediatric cardiac arrest. Our evidence up-date only identified 2 small studies that described feasibility. Therefore, a systematic review of pediatric cardiac arrest patients is not justified at this time.
This limited evidence in pediatrics is different to the expanded body of evidence for POCUS use during cardiac arrest in adult cardiac arrest with international recommendations on practice13.
We excluded two studies that reviewed use of POCUS in the delivery room during newborn resuscitation after birth. Both were small case series that concluded the use of ultrasound in the delivery room is feasible to detect reversible causes for cardiac arrest in the newborn infant. There was a systematic review to evaluate characteristics of POCUS in predicting poor outcomes in adult and pediatric traumatic cardiac arrest, 3 small pediatric studies were included in meta-analysis. Use of POCUS/echocardiography during delivery room resuscitation is a developing body of evidence they may contribute to future recommendations.
The Treatment Recommendation of 2020 has been downgraded to a GPS based on a rigorous scoping review in 2020 and evidence updates in 2022 and 2024
Good Practice Statement
For children in cardiac arrest, echocardiography may be considered to identify potentially treatable when appropriately skilled personnel are available, but the benefits must be carefully weighed against the known deleterious consequences of interrupting chest compressions
References
1. de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, et al. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2010;81 Suppl 1:e213-59.
2. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S876-908.
3. Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA2020: An R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis. Campbell Systematic Reviews. 2022;18(2):e1230.
4. Kool M, Atkins DL, Van de Voorde P, Maconochie IK, Scholefield BR, Force PIT. Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review. Resusc Plus. 2021;6:100109.
5. Morgan RW, Stinson HR, Wolfe H, Lindell RB, Topjian AA, Nadkarni VM, et al. Pediatric In-Hospital Cardiac Arrest Secondary to Acute Pulmonary Embolism. Crit Care Med. 2018;46(3):e229-e34.
6. Tsung JW, Blaivas M. Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: a case series. Resuscitation. 2008;77(2):264-9.
7. Leviter JI, Chen L, O'Marr J, Riera A. The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation. Pediatr Emerg Care. 2022.
8. Leviter JI, Walsh S, Riera A. Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases. Pediatr Emerg Care. 2022.
9. Miller AF, Piyawat A, Gravel CA, Viera RL, et al. Use of Cardiac Point-of Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care. 2022
10. Azzopardi E, Grech E, Grech V. Point of Care cardiac Ultrasonography in Three Paediatric Arrests.Malta Med J. 2023
11. Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021;161:327-87.
12. Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Jr., et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S469-s523.
13. Avila-Reyes D, Acevedo-cardona AO, Gomez-Gonzalez JF, Echeverry-Piedrahita DR, Aguirre-Florez M, Giraldo-Diaconeasa A. Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article. Ultrasound J. 2021;13(1):46.