Dallas 2015 TFQO: Vinay Nadkarni MD COI#249 EVREV 1: Graeme Maclaren MBBS COI#98 EVREV 2: Ravi Thiagarajan MBBS, MPH COI#149 Taskforce: PALS Peds 819 :

Dallas 2015

TFQO: Vinay Nadkarni MD COI#249EVREV 1: Graeme Maclaren MBBS COI#98EVREV 2: Ravi Thiagarajan MBBS, MPH COI#149Taskforce: PALS

Peds 819 : Pre-arrest Care of Pediatric Dilated

Cardiomyopathy or Myocarditis

Dallas 2015COI Disclosure (SPECIFIC to this systematic review)

Graeme Maclaren COI#98Commercial/industry• None

Potential intellectual conflicts• Chairman, Asia-Pacific Chapter, ELSO

Ravi Thiagarajan COI#149Commercial/industry• Bristol Myers Squibb (Events adjudication committee)

Potential intellectual conflicts• ELSO registry Co-Chair

Dallas 20152010 Treatment Recommendation

“Topic not reviewed in 2010”.

Dallas 2015C2015 PICO

Population: Pediatric patients with dilated Cardiomyopathy (DCM) or Myocarditis in a pre-arrest stateIntervention: Any Pre-Arrest managementComparison: Standard care/No treatmentOutcomes: 9-Critical Survival with Favorable neurological/ functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year7-Critical Survival to hospital discharge5-Important Cardiac arrest frequency5-Important ROSC

Dallas 2015Inclusion/Exclusion& Articles Found

Inclusions: Dilated Cardiomyopathy, Myocarditis, Children, shock, pre-arrest, cardiac arrest, pre-arrest treatment. We searched for RCTs and observational studies. We excluded studies with only post-arrest managementNumber of ArticlesSearch Identified: 548 articlesInitial review: 67 article (2 RCTs; 65 Non-RCTs); Excluded: 481Final Inclusion: 5 articles (All Non-RCTs; 1 not identified from initial search); Excluded 62

Dallas 2015

Included Articles

Lynch, Johanne; Pehora, Carolyne; Holtby, Helen; Schwarz, Steven M; Taylor, Katherine;Cardiac arrest upon induction of anesthesia in children with cardiomyopathy: an analysis of incidence and risk factors. Paediatr Anaesth Sep 2011; 21 (9): 951-7. Song, M.-K.;Baek, J.-S.;Kwon, B.-S.;Kim, G.-B.;Bae, E.-J.;Noh, C.-I.;Choi, J.-Y. Clinical spectrum and prognostic factors of pediatric ventricular tachycardia. : Circ. J. 2010; 74 (9): 1951-1958Eicken, Andreas; Kolb, Christof; Lange, Sylvia; Brodherr-Heberlein, Silke; Zrenner, Bernhard; Schreiber, Christian; Hess, John. Implantable cardioverter defibrillator (ICD) in children. Int. J. Cardiol. Feb-8-2006; 107 (1): 30-5.Greissman, A.;Silver, P.;Nimkoff, L.;Sagy, M. . Transvenous right ventricular pacing during cardiopulmonary resuscitation of pediatric patients with acute cardiomyopathy. PEDIATR. EMERG. CARE 1995; 11 (1): 17-24.Teele SA, Allan CK, Laussen PC, Newburger JW, Gauvreau K, Thiagarajan RR. Management and Outcomes in Pediatric Patients Presenting with Acute Fulminant Myocarditis. J Pediatr. 2011 Apr;158(4):638-643

Dallas 20152015 Proposed Treatment Recommendations

We suggest Implantable Cardiac Defibrillator (ICD) and Anti-arrhythmic medications for pre-arrest management of cardiac arrest in pediatric dilated cardiomyopathy or myocarditis (weak recommendation, very low quality evidence)

We suggest use of ECMO for patients with myocarditis presenting with dysrhythmia, lactic acidosis, renal, or hepatic dysfunction for consideration of ECMO (weak recommendation, very low quality evidence)

Dallas 2015 Risk of Bias in studies

No RCTs Included

Dallas 2015Evidence profile table(s)

Dallas 2015Proposed Consensus on Science statements

1. For the critical outcome of survival to hospital discharge, we have identified no evidence that a specific pre-arrest management strategy in patients with dilated cardiomyopathy (DCM) or myocarditis shows a benefit (Song, 2010, 1951; Eicken, 2006, 30)

2. For the critical outcome of survival to hospital discharge, we have identified no evidence that a specific anesthesia technique in patients with DCM shows benefit. The incidence of cardiac arrest in patient with DCM undergoing procedural anesthesia is low (1.7%). (Lynch, 2011, 951).

3. For the critical outcome of survival with good neurological outcome, we have identified very low quality evidence from an observational study of 12 children with DCM or myocarditis, and documented ventricular tachycardia, that use of ICD or anti-arrhythmic agents may not lead to improved outcome. The risk of inappropriate shock and complications could not be estimated from the study. (Song, 2010, 1951) 

4. For the critical outcome of survival to hospital discharge, we have identified very low quality evidence from an observational study of 20 children with acute myocarditis that demonstrated that the use of ECMO may lead to improved outcomes.  Cardiac arrest and need for ECMO was associated with those presenting with dysrhythmia, lactic acidosis, renal, or liver dysfunction, (Teele, 2011, 638).

Dallas 2015Draft Treatment Recommendations

We suggest that ECMO be used for patients with myocarditis presenting with high risk features (Arrhythmia, Lactic acidosis, Renal and liver dysfunction) and where the appropriate resources for this are available (weak recommendation based on very low quality evidence)

There is insufficient evidence upon which to base a recommendation for the empiric use of ICD or anti-arrhythmia medications for children with dilative cardiomyopathy or myocarditis in a pre-arrest state. (weak recommendation based on very low quality evidence)

Dallas 2015

Knowledge Gaps

Factors associated with cardiac arrest in patients with DCM or myocarditis have not been studied

There is little knowledge on benefits of pre-arrest initiation of inotropes/inodilators, mechanical ventilation, or ECMO on survival and neurological outcomes in children with DCM or myocarditis