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17706

Use of Procainamide In Pediatric Cardiac Arrest

Friday, October 19, 2012
Room 275-277 (Morial Convention Center)
Santiago O. Valdés, MD, Pediatric Cardiology, Baylor College of Medicine, Houston, TX, Aaron J. Donoghue, MD, Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, Derek B. Hoyme, MD, Pediatrics, University of Arizona, Tucson, AZ, Marc D. Berg, MD, Pediatric Critical Care, University of Arizona, Tucson, AZ, Robert A. Berg, MD, FAAP, FCCM, Childrens Hospital of Philadelphia, PA and Ricardo A. Samson, MD, FAAP, Pediatric Cardiology, University of Arizona, Tucson, AZ

Purpose: Current Pediatric Advance Life Support (PALS) guidelines recommend the use of amiodarone for cardiac arrest associated with refractory pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF). The recommendation is based on a single pediatric study and extrapolation from data in adults showing some treatment success of pVT/VF with amiodarone. An observational study in adults with out-of-hospital VF cardiac arrest showed that procainamide as a second line anti-arrhythmic was not associated with improved survival. No data regarding procainamide in the treatment of pVT/VF cardiac arrest are available in children.  We hypothesized that procainamide would not be associated with improved outcomes in pediatric pVT/VF cardiac arrest compared with other antiarrhythmic medications (AAR) or no anti-arrhythmic medications.

Methods: We queried the American Heart Association Get With The Guidelines Resuscitation (AHA-GWTG-R) database of in-hospital cardiac arrest to evaluate the use of procainamide in children having cardiac arrest with pVT/VF. The AHA-GWTG-R (formerly NRCPR) is a national registry of in-hospital cardiac arrest. It includes data from all cardiac arrests in 433 hospitals. We extracted and analyzed the records from the index pVT/VF event of patients 0-21 years of age. Utstein outcomes were compared between patients receiving procainamide and patients receiving lidocaine, amiodarone, both, or neither by chi square analysis.  Potentially confounding clinical factors (duration of CPR, number of defibrillations, number of epinephrine doses, and times to critical interventions) were compared between groups by Wilcoxon rank sum testing.

Results: Thirteen pediatric patients received procainamide out of 1,098 during a cardiac arrest with documented pVT /VF at some point during the arrest event, 7 as the initial arrest rhythm. Three patients received procainamide only and 10 received procainamide plus another AAR. Outcomes comparing these patients (PROC) versus patients receiving other AAR (amiodarone, lidocaine or both)(AAR) and patients receiving no anti-arrhythmic medications (No AAR) were as follows:

 

Patients

Survived Event

Survived 24 h

Survived to DC

PROC

13

7 (54%)

6 (46%)

2 (15%)

AAR

497

299 (60%)

p=0.78

212 (43%) p=0.79

114 (23%) p=0.74

No AAR

588

307 (52%)

p=1

215 (37%) p=0.56

132 (22%) p=0.74

There were no differences in outcomes or potential clinical confounders between groups.

Conclusions: Procainamide is rarely used for in-hospital pediatric pVT/VF. Rates of survival to discharge were not demonstrably different among the few pediatric patients with in-hospital pVT/VF who received procainamide versus those who received anti-arrhythmics other than procainamide or no anti-arrhythmics.  Important limitations include:  1) treatment biases (which patients were treated with procainamide); 2) inadequate power (only 13 children in the procainamide group); and 3) small numbers precluding adequate adjustment for potentially confounding variables.