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OBJECTIVE: To determine the utility of a disposable colorimetric end-tidal CO2 detector during pediatric cardiopulmonary resuscitation (CPR) for (1) confirming endotracheal tube (ETT) position, and (2) assessing the relationship between end-tidal CO2 recorded by this method and outcome of pediatric CPR. DESIGN/SETTING: Prospective observations during CPR in a university children's hospital. PARTICIPANTS: Forty children (28 male, 12 female) aged 1 week to 10 years (25 children aged < or = 1 year, mean age 27.2 months, median 7 months), weighing 2.5 to 40 kg (31 children weighing < or = 15 kg, mean 10.94 kg, median 7 kg) who underwent a total of 48 endotracheal intubations during CPR. METHODS: After intubation, ETT position was verified by usual clinical methods including direct visualization. The device was attached between the ETT and ventilation bag, the patient was manually ventilated, and a first reading was obtained. Any color change from purple (Area A, end-tidal CO2 < 0.5%) to tan or yellow (Area B or C, end-tidal CO2 > or = 0.5%) was considered to be positive for airway intubation. CPR was conducted as per Pediatric Advanced Life Support guidelines. A second reading was obtained when the decision to discontinue CPR was made. RESULTS: All nine esophageal tube positions were correctly identified by the detector. Thirty-three of 39 tracheal tube positions were correctly identified (P < .001). For verifying ETT position, the device had a sensitivity of 84.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 60%. Readings were obtained at the end of CPR in 25 patients. All 13 patients who regained spontaneous circulation and survived to ICU admission had a second reading in the C range, while none of the 12 patients with a second reading in the A or B range survived. Both the first and second end-tidal CO2 readings in the C range correlated significantly with short-term survival (P = .01 and P < .001, respectively). Two patients were eventually discharged from the hospital. CONCLUSIONS: During CPR a positive test confirms placement of the ETT within the airway, whereas a negative test indicates either esophageal intubation or airway intubation with poor or absent pulmonary blood flow and requires an alternate means of confirmation of tube position. The detector may be of prognostic value for return of spontaneous circulation and short-term survival.

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OBJECTIVE: To assess the experience and efficacy of extracorporeal membrane oxygenation (ECMO) for cardiac rescue in patients with presumptively lethal cardiac dysfunction at the Children's Hospital of Pittsburgh. DESIGN: Retrospective analysis of patient records from a 9-yr period. SETTING: A 22-bed tertiary care pediatric intensive care unit (ICU) with an average of 1,400 admissions per year. An average of 150 open cardiotomy surgeries are performed per year, and all postoperative and severely ill cardiac patients are cared for in the ICU. PATIENTS: A total of 29 pediatric ICU patients with myocardial failure received ECMO throughout the 9-yr study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic information, underlying cardiac defect, intraoperative and postoperative data, postoperative course, details of ECMO treatment, and outcome were collected. Comparison of survivors with nonsurvivors was performed using the Mann-Whitney U test for continuous variables. Twenty-three (79%) of 29 patients recovered myocardial function while undergoing ECMO, 18 (62%) of 29 patients were successfully decannulated, and 13 (45%) of 29 patients survived to hospital discharge. Long-term survival rate was 11 (38%) of 29 patients. Three (60%) of five bridge-to-heart transplant patients survived. Eleven (65%) of 17 patients who suffered cardiac arrest before ECMO, survived to discharge and nine (53%) of these 17 patients remain long-term survivors. Survival rate in patients who required cardiac massage for > 15 mins before cannulation was six (55%) of 11 patients. CONCLUSIONS: Patients with severe myocardial dysfunction who fail conventional therapy can be successfully supported with ECMO during the period of myocardial recovery. ECMO can also provide a viable circulatory support system in patients with prolonged cardiac arrest who fail conventional resuscitation techniques. ECMO is also an effective means of support as a mechanical bridge to heart transplantation.

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BACKGROUND: Conventional cardiopulmonary resuscitation (CPR) for cardiac arrest after open-heart surgery in children is often unsuccessful despite the ability to perform open-chest massage. The purpose of this study was to review our results with mechanical support as rescue therapy in children with sudden circulatory arrest after cardiac surgery. METHODS AND RESULTS: From 1981 through 1991, we have used mechanical support with an extracorporeal membrane oxygenator (ECMO) circuit for cardiac support in 33 children. Eleven of the 33 patients (age, 15 +/- 7 months) suffered cardiac arrest intractable to conventional open-chest massage 39 +/- 15 hours after an open-heart procedure. The mean duration of CPR was 65 +/- 9 minutes until ECMO flow was started. ECMO support was continued for 112 +/- 8 hours. One patient had ECMO discontinued due to bleeding (survived); three were discontinued from ECMO and died from neurological complications; and one died of cardiac dysfunction. Sepsis on ECMO was seen in one patient (survived). Overall early survival was seven of 11 (64%) with one patient requiring heart transplantation due to irreversible cardiac dysfunction. One child died late (1 month) after ECMO support. There were no long-term sequelae in the survivors. CONCLUSIONS: We conclude that ECMO rescue in children with postcardiotomy cardiac arrest is a feasible option in selected patients even after prolonged CPR (as long as 60 minutes).

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OBJECTIVE: To determine whether abnormalities in lung mechanics detected in infants during the acute phase of meconium aspiration syndrome persist after treatment with extracorporeal membrane oxygenation (EMCO). DESIGN: Prospective, descriptive study. Prospective evaluation of airway function and lung mechanics during and after ECMO by pulmonary function testing at 1.8 +/- 0.5 days of EMCO (period 1), follow-up at 1.4 +/- 0.2 days (period 2), and 7.0 +/- 0.9 days (period 3) after decannulation from ECMO. SETTING: Tertiary care neonatal/pediatric ICU. PATIENTS: Twelve neonates undergoing ECMO treatment for severe meconium aspiration syndrome that was refractory to conventional mechanical ventilation. INTERVENTIONS: Maximum expiratory flow-volume curves were studied with the deflation flow-volume curve technique, and compliance and resistance of the respiratory system were studied with partial passive flow-volume curves. MEASUREMENTS AND MAIN RESULTS: Respiratory system compliance was the only index of respiratory mechanics that was significantly (p less than .05) improved (0.96 +/- 0.1 vs. 0.61 +/- 0.1 mL/cm H2O/kg) immediately after decannulation from ECMO compared with period 1. Clinically important (p less than .05) improvement in forced vital capacity (28.0 +/- 5.5 vs. 16.1 +/- 1.9 mL/kg), respiratory system compliance (1.01 +/- 0.2 vs. 0.61 +/- 0.1 mL/cm H2O/kg), and maximum expiratory flow at 25%/forced vital capacity (1.0 +/- 0.3 vs. 2.2 +/- 0.3) was evident only during period 3 compared with period 1. CONCLUSIONS: We conclude that improvements in the clinical condition and oxygenation, permitting successful decannulation from ECMO, are achieved before clinically important improvements in lung mechanics.

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BACKGROUND AND METHODS: the most reliable methods for confirming endotracheal tube placement are direct visualization of passage through the vocal cords and documentation of CO2 in the expired gas. We evaluated the use of a disposable colorimetric CO2 detector for verifying endotracheal tube position in small animals. The end-tidal CO2 (Petco2) detector was tested in 11 piglets with the endotracheal tube sequentially in the trachea, the esophagus, the esophagus with a carbonated beverage in the stomach, the esophagus after bag-mask ventilation. Endotracheal tube position was confirmed in all cases by direct visualization and capnometry. RESULTS: The Petco2 detector identified the tube placement accurately in all 54 (21 tracheal, 33 esophageal) intubations (p less than .001). CONCLUSIONS: This disposable Petco2 detector is highly sensitive and specific for verifying endotracheal tube placement in this nonarrest piglet model.

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The safety and risks of percutaneous infraclavicular subclavian vein catheterization, when performed by nonsurgical staff, were studied prospectively in 100 consecutive patients. The overall success rate was 92% (with one attempt, 45%; with two attempts, 85%). The procedure was performed under emergency conditions in 35% of the patients, with a success rate of 88.6%. The success rate was significantly lower in younger patients. Hemodynamic status, respiratory status, and level of expertise of the individual performing catheterization did not affect success rate. Most of the failures (six of eight) were related to presumed thrombosis from prior cannulation of the superior vena cava. Mean duration of catheterization was 7.5 +/- 5.8 days (+/- SD). Minor complications (n = 24) included hematomas, minor bleeding from subclavian artery puncture, and transient premature ventricular ectopic beats. Major complications (n = 6) were pneumothoraces (n = 4) and catheter-related infection (n = 2). The number of attempts made to catheterize the vessel and the level of expertise of the operator had the greatest effect on complication rates. No mortality was associated with this procedure. We have found percutaneous infraclavicular subclavian vein catheterization to be a rapid alternative to surgical cutdown for venous access during cardiopulmonary resuscitation. Pediatric residents can be trained, under direct supervision, to perform this procedure with a high success rate and a low complication rate.

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