Factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study

Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study

AIMS

The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes.

DESIGN

A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes.

SETTING

Hospitals reporting to the American Heart Association's Get With The Guidelines®- Resuscitation registry (2007-2021).

PATIENTS

Children with index IHCA with an invasive airway or arterial line at the time of arrest.

RESULTS

Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03).

CONCLUSIONS

Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.

Evaluation of Serum Biomarkers and Electroencephalogram to Determine Survival Outcomes in Pediatric Post-Cardiac-Arrest Patients

Cardiac arrest causes primary and secondary brain injuries. We evaluated the association between neuron-specific enolase (NSE), serum S-100B (S100B), electroencephalogram (EEG) patterns, and post-cardiac arrest outcomes in pediatric patients. A prospective observational study was conducted in the pediatric intensive care unit and included 41 post-cardiac arrest patients who underwent EEG and serum sampling for NSE and S100B. The participants were aged 1 month to 18 years who experienced cardiac arrest and underwent CPR after a sustained return of spontaneous circulation for ≥48 h. Approximately 19.5% (n = 8) of patients survived until ICU discharge. Convulsions and sepsis were significantly associated with higher mortality (relative risk: 1.33 [95% CI = 1.09-1.6] and 1.99 [95% CI = 0.8-4.7], respectively). Serum NSE and S100B levels were not statistically associated with the outcome (p = 0.278 and 0.693, respectively). NSE levels were positively correlated with the duration of CPR. EEG patterns were significantly associated with the outcome (p = 0.01). Non-epileptogenic EEG activity was associated with the highest survival rate. Post-cardiac arrest syndrome is a serious condition with a high mortality rate. Management of sepsis and convulsions affects prognosis. We believe that NSE and S100B may have no benefit in survival evaluation. EEG can be considered for post-cardiac arrest patients.

Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study

Aim

In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country.

Methods

This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days.

Results

Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007-0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065-0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069-0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014-0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130-0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days.

Conclusion

In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.

Validation of a modified bedside Pediatric Early Warning System score for detection of clinical deterioration in hospitalized pediatric oncology patients: A prospective cohort study

BACKGROUND

Hospitalized pediatric oncology patients are at risk of severe clinical deterioration. Yet Pediatric Early Warning System (PEWS) scores have not been prospectively validated in these patients. We aimed to determine the predictive performance of the modified BedsidePEWS score for unplanned pediatric intensive care unit (PICU) admission and cardiopulmonary resuscitation (CPR) in this patient population.

METHODS

We performed a prospective cohort study in an 80-bed pediatric oncology hospital in the Netherlands, where care has been nationally centralized. All hospitalized pediatric oncology patients aged 0-18 years were eligible for inclusion. A Cox proportional hazard model was estimated to study the association between BedsidePEWS score and unplanned PICU admissions or CPR. The predictive performance of the model was internally validated by bootstrapping.

RESULTS

A total of 1137 patients were included. During the study, 103 patients experienced 127 unplanned PICU admissions and three CPRs. The hazard ratio for unplanned PICU admission or CPR was 1.65 (95% confidence interval [CI]: 1.59-1.72) for each point increase in the modified BedsidePEWS score. The discriminative ability was moderate (D-index close to 0 and a C-index of 0.83 [95% CI: 0.79-0.90]). Positive and negative predictive values of modified BedsidePEWS score at the widely used cutoff of 8, at which escalation of care is required, were 1.4% and 99.9%, respectively.

CONCLUSION

The modified BedsidePEWS score is significantly associated with requirement of PICU transfer or CPR. In pediatric oncology patients, this PEWS score may aid in clinical decision-making for timing of PICU transfer.

Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial

OBJECTIVES

To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA).

DESIGN

Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial.

SETTING

Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497).

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621).

CONCLUSIONS

In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.

The predictive performance and impact of pediatric early warning systems in hospitalized pediatric oncology patients-A systematic review

Pediatric early warning systems (PEWS) arewidely used to identify clinically deteriorating patients. Hospitalized pediatric oncology patients are particularly prone to clinical deterioration. We assessed the PEWS performance to predict early clinical deterioration and the effect of PEWS implementation on patient outcomes in pediatric oncology patients. PubMED, EMBASE, and CINAHL databases were systematically searched from inception up to March 2020. Quality assessment was performed using the Prediction model study Risk-Of-Bias Assessment Tool (PROBAST) and the Cochrane Risk-of-Bias Tool. Nine studies were included. Due to heterogeneity of study designs, outcome measures, and diversity of PEWS, it was not possible to conduct a meta-analysis. Although the studies reported high sensitivity, specificity, and area under the receiver operating characteristics curve (AUROC) of PEWS detecting inpatient deterioration, overall risk of bias of the studies was high. This review highlights limited evidence on the predictive performance of PEWS for clinical deterioration and the effect of PEWS implementation.

The Value of the Biomarkers Neuron-Specific Enolase and S100 Calcium-Binding Protein for Prediction of Mortality in Children Resuscitated After Cardiac Arrest

The aim of the present study was to assess the ability of the biomarkers neuron-specific enolase (NSE) and S100 calcium-binding protein b (S100b) to predict 30 day mortality in children resuscitated from cardiac arrest (CA). It was a prospective observational study at a single tertiary heart centre. Consecutive children were admitted after resuscitated in-hospital and out-of-hospital CA. Levels of NSE and S100b were analyzed from 12 to 24 hours, from 24 to 48 hours, and from 48 to 72 hours after admission. The primary endpoint was 30-day mortality. Differences in biomarker levels between survivors and non-survivors were analyzed with the Mann-Whitney U test. Receiver operating characteristics (ROC) curves were applied to assess the predictive ability of the biomarkers and the areas under the ROC curves (AUC) were presented. A total of 32 resuscitated CA patients were included, and 12 (38%) patients died within 30 days after resuscitation. We observed significantly higher levels of NSE and S100b in non-survivors compared to survivors at all timepoints from 12 to 72 hours after CA. NSE achieved AUCs from 0.91-0.98 for prediction of 30 day mortality, whereas S100b achieved AUCs from 0.93-0.94. An NSE cut-off of 61 μg/L sampled between 12-24 hours from admission achieved a sensitivity of 80% and a specificity of 100% for prediction of 30 day mortality. In children resuscitated from CA, the biomarkers NSE and S100b appear to be solid predictors of mortality after 30 days.

Risk Factors and Neurologic Outcomes Associated With Resuscitation in the Pediatric Intensive Care Unit

In the pediatric intensive care unit (PICU), cardiac arrest (CA) is rare but results in high rates of morbidity and mortality. A retrospective chart review of 223 patients who suffered from in-PICU CA was analyzed from January 2017 to December 2020. Outcomes at discharge were evaluated using pediatric cerebral performance category (PCPC). Return of spontaneous circulation was attained by 167 (74.8%) patients. In total, only 58 (25%) patients survived to hospital discharge, and 49 (21.9%) of the cohort had good neurologic outcomes. Based on multivariate logistic regression analysis, vasoactive-inotropic drug usage before CA, previous PCPC scale >2, underlying hemato-oncologic disease, and total time of CPR were risk factors associated with poor outcomes. Furthermore, we determined the cutoff value of duration of CPR in predicting poor neurologic outcomes and in-hospital mortality in patients caused by in-PICU CA as 17 and 23.5 min respectively.

Pediatric In-Hospital Cardiac Arrest International Registry (PACHIN): protocol for a prospective international multicenter register of cardiac arrest in children

Background and aims

Cardiac arrest (CA) in children is a major public health problem. Thanks to advances in cardiopulmonary resuscitation (CPR) guidelines and teaching skills, results in children have improved. However, pediatric CA has a very high mortality. In the treatment of in-hospital CA there are still multiple controversies. The objective of this study is to develop a multicenter and international registry of in-hospital pediatric cardiac arrest including the diversity of management in different clinical and social contexts. Participation in this register will enable the evaluation of the diagnosis of CA, CPR and post-resuscitation care and its influence in survival and neurological prognosis.

Methods

An intrahospital CA data recording protocol has been designed following the Utstein model. Database is hosted according to European legislation regarding patient data protection. It is drafted in English and Spanish. Invitation to participate has been sent to Spanish, European and Latinamerican hospitals. Variables included, asses hospital characteristics, the resuscitation team, patient’s demographics and background, CPR, post-resuscitation care, mortality, survival and long-term evolution. Survival at hospital discharge will be evaluated as a primary outcome and survival with good neurological status as a secondary outcome, analyzing the different factors involved in them. The study design is prospective, observational registry of a cohort of pediatric CA.

Conclusions

This study represents the development of a registry of in-hospital CA in childhood. Its development will provide access to CPR data in different hospital settings and will allow the analysis of current controversies in the treatment of pediatric CA and post-resuscitation care. The results may contribute to the development of further international recommendations.

Trial register: ClinicalTrials.gov Identifier: NCT04675918. Registered 19 December 2020 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04675918?cond=pediatric+cardiac+arrest&draw=2&rank=10

[Novelties in the paediatric cardiopulmonary resuscitation recommendations and lines of development in Spain]

OBJECTIVES

To analyse the 2020 international and European recommendations for paediatric cardiopulmonary resuscitation (CPR), highlight the most important changes and propose lines of development in Spain.

METHODS

Critical analysis of the paediatric cardiopulmonary resuscitation recommendations of the European Resuscitation Council.

RESULTS

The most relevant changes in the CPR recommendations for 2020 are in basic CPR the possibility of activating the emergency system after performing the five rescue ventilations with the mobile phone on loudspeaker, and in advanced CPR, bag ventilation between two rescuers if possible, the administration of epinephrine as soon as a vascular access is obtained, the increase in the respiratory rate in intubated children between 10 and 25bpm according to their age and the importance of controlling the quality and coordination of CPR. In CPR training, the importance of training non-technical skills such as teamwork, leadership and communication and frequent training to reinforce and maintain competencies is highlighted.

CONCLUSIONS

It is essential that training in paediatric CPR in Spain follows the same recommendations and is carried out with a common methodology, adapted to the characteristics of health care and the needs of the students. The Spanish Paediatric and Neonatal Cardiopulmonary Resuscitation Group should coordinate this process, but the active participation of all paediatricians and health professionals who care for children is also essential.

Impact of a shared decision-making mHealth tool on caregivers' team situational awareness, communication effectiveness, and performance during pediatric cardiopulmonary resuscitation: study protocol of a cluster randomized controlled trial

Background

Effective team communication, coordination, and situational awareness (SA) by team members are critical components to deliver optimal cardiopulmonary resuscitation (CPR). Complexity of care during CPR, involvement of numerous providers, miscommunication, and other exogenous factors can all contribute to negatively influencing patient care, thus jeopardizing survival. We aim to investigate whether an mHealth supportive tool (the Interconnected and Focused Mobile Apps on patient Care Environment [InterFACE]) developed as a collaborative platform to support CPR providers in real-time and share patient-centered information would increase SA during pediatric CPR.

Methods

We will conduct a prospective, cluster randomized controlled trial by groups of 6 participants in a tertiary pediatric emergency department (33,000 consultations/year) with pediatric physicians and nurses. We will compare the impact of the InterFACE tool with conventional communication methods on SA and effective team communication during a standardized pediatric in-hospital cardiac arrest and a polytrauma high-fidelity simulations. Forty-eight participants will be randomized (1:1) to consecutively perform two 20-min video-recorded scenarios using either the mHealth tool or conventional methods. The primary endpoint is the SA score, measured with the Situation Awareness Global Assessment Technique (SAGAT) instrument. Enrollment will start in late 2020 and data analysis in early 2021. We anticipate that the intervention will be completed by early 2021 and study results will be submitted in mid 2021 for publication.

Discussion

This clinical trial will assess the impact of a collaborative mHealth tool on increasing situational awareness and effective team communication during in-hospital pediatric resuscitation. As research in this area is scarce, the results generated by this study may become of paramount importance in improving the care of children receiving in-hospital CPR, in the era of increasing communication technology.

Trial registration

ClinicalTrials.gov NCT04464603. Registered on 9 July 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05170-3.

Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system.

RESULTS

We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low.

CONCLUSIONS

This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations.

TRIAL REGISTRATION

The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Pediatric Cardiac Arrest Resuscitation

Pediatric cardiac arrest is a relatively rare but devastating presentation in infants and children. In contrast to adult patients, in whom a primary cardiac dysrhythmia is the most likely cause of cardiac arrest, pediatric patients experience cardiovascular collapse most frequently after an initial respiratory arrest. Aggressive treatment in the precardiac arrest state should be initiated to prevent deterioration and should focus on support of oxygenation, ventilation, and hemodynamics, regardless of the presumed cause. Unfortunately, outcomes for pediatric cardiac arrest, whether in hospital or out of hospital, continue to be poor.

Effect of ventilation rate on recovery after cardiac arrest in a pediatric animal model

AIMS

To assess the impact of two different respiratory rates in hemodynamic, perfusion and ventilation parameters in a pediatric animal model of cardiac arrest (CA).

METHODS

An experimental randomized controlled trial was carried out in 50 piglets under asphyxial CA. After ROSC, they were randomized into two groups: 20 and 30 respirations per minute (rpm). Hemodynamic, perfusion and ventilation parameters were measured 10 minutes after asphyxia, just before ROSC and at 5, 15, 30 and 60 minutes after ROSC. Independent medians test, Kruskal-Wallis test and χ2 test, were used to compare continuous and categorical variables, respectively. Spearman's Rho was used to assess correlation between continuous variables. A p-value <0.05 was considered significant.

RESULTS

Arterial partial pressure of carbon dioxide (PaCO2) was significantly lower in the 30 rpm group after 15 minutes (41 vs. 54.5 mmHg, p <0.01), 30 minutes (39.5 vs. 51 mmHg, p < 0.01) and 60 minutes (36.5 vs. 48 mmHg, p = 0.02) of ROSC. The percentage of normoventilated subjects (PaCO2 30-50 mmHg) was significantly higher in the 30 rpm group throughout the experiment. pH normalization occurred faster in the 30 rpm group with significant differences at 60 minutes (7.40 vs. 7.34, p = 0.02). Lactic acid levels were high immediately after ROSC in both groups, but were significantly lower in the 20 rpm group at 30 (3.7 vs. 4.7 p = 0.04) and 60 minutes (2.6 vs. 3.6 p = 0.03).

CONCLUSIONS

This animal model of asphyxial CA shows that a respiratory rate of 30 rpm is more effective to reach normoventilation than 20 rpm in piglets after ROSC. This ventilation strategy seems to be safe, as it does not cause hyperventilation and does not affect hemodynamics or cerebral tissue perfusion.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival.

SOURCE OF DATA

This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles.

SYNTHESIS OF DATA

The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting.

CONCLUSIONS

A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

The Impact of a Tablet App on Adherence to American Heart Association Guidelines During Simulated Pediatric Cardiopulmonary Resuscitation: Randomized Controlled Trial

Background

Evidence-based best practices are the cornerstone to guide optimal cardiopulmonary arrest resuscitation care. Adherence to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite advances in resuscitation science and survival improvement over the last decades, only approximately 38% of children survive to hospital discharge after in-hospital cardiac arrest and only 6%-20% after out-of-hospital cardiac arrest.

Objective

We investigated whether a mobile app developed as a guide to support and drive CPR providers in real time through interactive pediatric advanced life support (PALS) algorithms would increase adherence to AHA guidelines and reduce the time to initiation of critical life-saving maneuvers compared to the use of PALS pocket reference cards.

Methods

This study was a randomized controlled trial conducted during a simulation-based pediatric cardiac arrest scenario caused by pulseless ventricular tachycardia (pVT). A total of 26 pediatric residents were randomized into two groups. The primary outcome was the elapsed time in seconds in each allocation group from the onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, including the time intervals between defibrillation attempts and drug doses, shock doses, and the number of shocks. All outcomes were assessed for deviation from AHA guidelines.

Results

Mean time to the first defibrillation attempt (121.4 sec, 95% CI 105.3-137.5) was significantly reduced among residents using the app compared to those using PALS pocket cards (211.5 sec, 95% CI 162.5-260.6, P<.001). With the app, 11 out of 13 (85%) residents initiated chest compressions within 60 seconds from the onset of pVT and 12 out of 13 (92%) successfully defibrillated within 180 seconds. Time to all other defibrillation attempts was reduced with the app. Adherence to the 2018 AHA pVT algorithm improved by approximately 70% (P=.001) when using the app following all CPR sequences of action in a stepwise fashion until return of spontaneous circulation. The pVT rhythm was recognized correctly in 51 out of 52 (98%) opportunities among residents using the app compared to only 19 out of 52 (37%) among those using PALS cards (P<.001). Time to epinephrine injection was similar. Among a total of 78 opportunities, incorrect shock or drug doses occurred in 14% (11/78) of cases among those using the cards. These errors were reduced to 1% (1/78, P=.005) when using the app.

Conclusions

Use of the mobile app was associated with a shorter time to first and subsequent defibrillation attempts, fewer medication and defibrillation dose errors, and improved adherence to AHA recommendations compared with the use of PALS pocket cards.

Quality of chest compressions during pediatric resuscitation with 15:2 and 30:2 compressions-to-ventilation ratio in a simulated scenario

The main objetive was to compare 30:2 and 15:2 compression-to-ventilation ratio in two simulated pediatric cardiopulmonary resuscitation (CPR) models with single rescuer. The secondary aim was to analyze the errors or omissions made during resuscitation. A prospective randomized parallel controlled study comparing 15:2 and 30:2 ratio in two manikins (child and infant) was developed. The CPR was performed by volunteers who completed an basic CPR course. Each subject did 4 CPR sessions of 3 minutes each one. Depth and rate of chest compressions (CC) during resuscitation were measured using a Zoll Z series defibrillator. Visual assessment of resuscitation was performed by an external researcher. A total of 26 volunteers performed 104 CPR sessions. Between 54–62% and 44–53% of CC were performed with an optimal rate and depth, respectively, with no significant differences. No differences were found in depth or rate of CC between 15:2 and 30:2 compression-to-ventilation ratio with both manikins. In the assessment of compliance with the ERC CPR algorithm, 69.2–80.8% of the subjects made some errors or omissions during resuscitation, the most frequent was not asking for help and not giving rescue breaths. The conclusions were that a high percentage of CC were not performed with optimal depth and rate. Errors or omissions were frequently made by rescuers during resuscitation.

Simulating blood pressure and end tidal CO2 in a CPR training manikin

BACKGROUND AND OBJECTIVE

The American Heart Association supports titrating the mechanics of cardiopulmonary resuscitation (CPR) to blood pressure and end tidal carbon dioxide (ETCO2) thresholds during in-hospital cardiac arrest. However, current CPR manikin training systems do not prepare clinicians to use these metrics to gauge their performance, and currently provide only feedback on hand placement, depth, rate, release, and interruptions of chest compressions. We addressed this training hardware deficiency through development of a novel CPR training manikin that displays simulated blood pressure and ETCO2 waveforms in real time on a simulated clinical monitor visible to the learner, reflecting the mechanics of chest compressions provided to the manikin. Such a manikin could improve clinicians' CPR technique while also training them to titrate CPR quality to physiologic blood pressure and ETCO2 targets as performance indicators.

METHODS

We used data and key findings from 4 human and 6 animal studies (including 132 human subjects, 61 pigs, and 16 dogs in total) to develop an algorithm that simulates blood pressure and ETCO2 waveforms based on compression mechanics for a pediatric patient. We modified an off-the-shelf infant manikin to incorporate a microcontroller sufficient to process the aforementioned algorithm, and a tablet computer to wirelessly display the simulated waveform. We recruited clinicians with in-hospital CPR experience to perform compressions with the manikin and complete a post-test survey on their satisfaction with designated elements of the manikin and display.

RESULTS

34 clinicians performed CPR on the prototype manikin system that simulates real-time bedside monitoring of blood pressure and ETCO2. 100% of clinicians surveyed reported "satisfaction" with the blood pressure waveform. 97% said they thought depth was accurately reflected in blood pressure (0% inaccurate, 3% not sure). 88% reported an accurate chest compression rate modification effect on blood pressure and ETCO2 (3% inaccurate, 9% not sure) and 59% an accurate effect of leaning (6% inaccurate, 35% not sure). Most importantly, all 34 respondents responded "yes" when asked if they thought this system would be helpful for CPR training.

CONCLUSION

A CPR manikin that simulates blood pressure and ETCO2 was successfully developed with acceptable relevance, performance and feasibility as a CPR quality training tool.

Predictors of mortality after admission to pediatric intensive care unit in oncohematologic patients without history of hematopoietic stem cell transplantation: A single-center experience

BACKGROUND

Pediatric oncohematologic patients are a high-risk population for clinical deterioration that might require pediatric intensive care unit (PICU) admission. Several studies have described outcomes and mortality predictors for patients post hematopoietic stem cell transplantation (HSCT), but fewer data exist regarding the category of non-HSCT patients.

PROCEDURE

All oncohematologic non-HSCT patients ≤18 years requiring PICU admission from 1998 to 2015 in our tertiary-care academic hospital were retrospectively evaluated by means of the pediatric hematology-oncology unit database and the Italian PICUs data network database. We assessed the relation between demographic and clinical characteristics and 90-day mortality after PICU admission.

RESULTS

Of 3750 hospitalized oncohematologic patients, 3238 were non-HSCT and 63 (2%) of them were admitted to the PICU. Patients were mainly affected by hematological malignancies (70%) and mostly were in the induction-therapy phase. The main reasons for admission were respiratory failure (40%), sepsis (25%), and seizures (16%). The median PICU stay was 5 days (range 1-107). The mortality rate at PICU discharge was 30%, and at 90 days it was 35%. Fifty-five percent of deaths happened in the first 2 days of the PICU stay. Cardiac arrest (P = .007), presence of disseminated intravascular coagulation (DIC, P = .007), and acute kidney injury (AKI) at PICU admission (P < .001) and during PICU stay (P = .021) were significant predictors of mortality in the multivariate analysis. Respiratory failure and mechanical ventilation were not associated with mortality.

CONCLUSIONS

A relatively small percentage of non-HSCT patients required PICU admission, but the mortality rate was still high. Hemodynamic instability, DIC, and AKI, but not respiratory failure, were significant predictors of mortality.

Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

Association of Severe Hyperoxemia Events and Mortality Among Patients Admitted to a Pediatric Intensive Care Unit

IMPORTANCE

A high Pao2, termed hyperoxemia, is postulated to have deleterious health outcomes. To date, the association between hyperoxemia during the ongoing management of critical illness and mortality has been incompletely evaluated in children.

OBJECTIVE

To examine whether severe hyperoxemia events are associated with mortality among patients admitted to a pediatric intensive care unit (PICU).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted over a 10-year period (January 1, 2009, to December 31, 2018); all 23 719 PICU encounters at a quaternary children's hospital with a documented arterial blood gas measurement were evaluated.

EXPOSURES

Severe hyperoxemia, defined as Pao2 level greater than or equal to 300 mm Hg (40 kPa).

MAIN OUTCOMES AND MEASURES

The highest Pao2 values during hospitalization were dichotomized according to the definition of severe hyperoxemia and assessed for association with in-hospital mortality using logistic regression models incorporating a calibrated measure of multiple organ dysfunction, extracorporeal life support, and the total number of arterial blood gas measurements obtained during an encounter.

RESULTS

Of 23 719 PICU encounters during the inclusion period, 6250 patients (13 422 [56.6%] boys; mean [SD] age, 7.5 [6.6] years) had at least 1 measured Pao2 value. Severe hyperoxemia was independently associated with in-hospital mortality (adjusted odds ratio [aOR], 1.78; 95% CI, 1.36-2.33; P < .001). Increasing odds of in-hospital mortality were observed with 1 (aOR, 1.47; 95% CI, 1.05-2.08; P = .03), 2 (aOR, 2.01; 95% CI, 1.27-3.18; P = .002), and 3 or more (aOR, 2.53; 95% CI, 1.62-3.94; P < .001) severely hyperoxemic Pao2 values obtained greater than or equal to 3 hours apart from one another compared with encounters without hyperoxemia. A sensitivity analysis examining the hypothetical outcomes of residual confounding indicated that an unmeasured binary confounder with an aOR of 2 would have to be present in 37% of the encounters with severe hyperoxemia and 0% of the remaining cohort to fail to reject the null hypothesis (aOR of severe hyperoxemia, 1.31; 95% CI, 0.99-1.72).

CONCLUSIONS AND RELEVANCE

Greater numbers of severe hyperoxemia events appeared to be associated with increased mortality in this large, diverse cohort of critically ill children, supporting a possible exposure-response association between severe hyperoxemia and outcome in this population. Although further prospective evaluation appears to be warranted, this study's findings suggest that guidelines for ongoing management of critically ill children should take into consideration the possible detrimental effects of severe hyperoxemia.

Developmental Outcome in Infants with Cardiovascular Disease After Cardiopulmonary Resuscitation: A Pilot Study

Unfavorable neurological outcome in children after cardiopulmonary resuscitation in infancy is frequent. However, few studies have investigated the development of these patients using comprehensive developmental tests and the feasibility of the Bayley Scales of Infant Development, 3rd Edition (BSID-III) has not been reported for this population. In this cross-sectional pilot study, we assessed the cognitive, language, and motor development in infants after cardiopulmonary resuscitation of ≥ 5 min with the BSID-III at the age of 12 or 24 months, depending on recruitment age. For analysis, 11 patients with in-hospital (n = 8) and out-of-hospital (n = 3) cardiac arrest were included. BSID-III results could not be quantified in three patients because of visual/hearing and/or motor impairment. In patients with quantifiable scores, 50.0% scored average in composite BSID-III scores, while the other 50.0% showed developmental delays, scoring distinctly below average. We conclude that the BSID-III is feasible for developmental assessment in the majority of the study population, but the use of instruments suitable for hearing/visually impaired and/or severely disabled infants is crucial to avoid biased results. Accurate characterization of developmental deficits is important to facilitate early identification and therapy of deficits.

Effect of healthcare spending on the relationship between the Human Development Index and maternal and neonatal mortality

Background

Several factors affect morbidity and mortality the world over. Previous research shows mortality rates are higher among individuals of lower socio-economic status. We investigated the trajectory of neonatal (NM) and maternal (MM) mortality between 2010 and 2014 and the effect of healthcare spending on the relationship between the Human Development Index (HDI) and NM and MM.

Methods

Data were obtained from the United Nations Development Program and World Bank. Latent growth curve models (LGCMs) were estimated to determine the trajectory of NM and MM across the study period and the effect of the HDI on NM and MM. Mediation analysis was used to determine if healthcare expenditure mediated the relationship between HDI and NM and MM rates. ArcGIS (Esri, Redlands, CA, USA) was used to generate a choropleth map of changes in NM and MM between 2010 and 2014.

Findings

Results showed many countries in Africa enjoyed decreases in NM and MM between 2010 and 2014, but other countries (Algeria, Libya and Sudan) showed little or no improvement. The LGCM for NM (Comparative Fit Index=0.956) and MM (CFI=0.963) demonstrated good fit to the data and showed that the HDI was negatively related to NM and MM. Mediation analysis showed that healthcare spending mediated the relationship between NM and MM in each year.

Conclusions

Given that healthcare spending can mediate the relationship between HDI and NM and MM, increases in healthcare spending among countries with low HDI could improve NM and MM outcomes.

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Latin American Consensus for Pediatric Cardiopulmonary Resuscitation 2017: Latin American Pediatric Critical Care Society Pediatric Cardiopulmonary Resuscitation Committee

OBJECTIVES

To develop a Latin American Consensus about Pediatric Cardiopulmonary Resuscitation. To clarify, reinforce, and adapt some specific recommendations for pediatric patients and to stimulate the implementation of these recommendations in clinical practice.

DESIGN

Expert consensus recommendations with Delphi methodology.

SETTING

Latin American countries.

SUBJECTS

Experts in pediatric cardiopulmonary resuscitation from 19 Latin American countries.

INTERVENTIONS

Delphi methodology for expert consensus.

MEASUREMENTS AND MAIN RESULTS

The goal was to reach consensus with all the participating experts for every recommendation. An agreement of at least 80% of the participating experts had to exist in order to deliver a recommendation. Two Delphi voting rounds were sent out electronically. The experts were asked to score between 1 and 9 their level of agreement for each recommendation. The score was then classified into three groups: strong agreement (score 7-9), moderate agreement (score 4-6), and disagreement (score 1-3). Nineteen experts from 19 countries participated in both voting rounds and in the whole process of drafting the recommendations. Sixteen recommendations about organization of cardiopulmonary resuscitation, prevention, basic resuscitation, advanced resuscitation, and postresuscitation measures were approved. Ten of them had a consensus of 100%. Four of them were agreed by all the participants except one (94.7% consensus). One recommendation was agreed by all except two experts (89.4%), and finally, one was agreed by all except three experts (84.2%). All the recommendations reached a level of agreement.

CONCLUSIONS

This consensus adapts 16 international recommendations to Latin America in order to improve the practice of cardiopulmonary resuscitation in children. Studies should be conducted to analyze the effectiveness of the implementation of these recommendations.

[Ventilation during cardiopulmonary resuscitation in the infant. Mouth to mouth and nose, or bag-valve-mask? A quasi-experimental study]

INTRODUCTION

It has been observed that health professionals have difficulty performing quality cardiopulmonary resuscitation (CPR). The aim of this study was to compare the quality of ventilations performed by Nursing students on an infant model using different methods (mouth-to-mouth-and-nose or bag-valve-mask).

MATERIAL AND METHODS

A quasi-experimental cross-sectional study was performed that included 46 second-year Nursing students. Two quantitative 4-minute tests of paediatric CPR were performed: a) mouth-to-mouth-and-nose ventilations, and b) ventilations with bag-valve-mask. A Resusci Baby QCPR Wireless SkillReporter® mannequin from Laerdal was used. The proportion of ventilations with adequate, excessive, and insufficient volume was recorded and analysed, as well as the overall quality of the CPR (ventilations and chest compressions).

RESULTS

The students were able to give a higher number of ventilations with adequate volume using the mouth-to-mouth-and-nose method (55±22%) than with the bag-valve-mask (28±16%, P<.001). The overall quality of the CPR was also significantly higher when using the mouth-to-mouth-and-nose method (60±19 vs. 48±16%, P<.001).

CONCLUSIONS

Mouth-to-mouth-and-nose ventilation method is more efficient than bag-valve-mask ventilations in CPR performed by nursing students with a simulated infant model.

Ventilation during cardiopulmonary resuscitation in children: a survey on clinical practice

BACKGROUND

This study aimed to investigate the ventilation practice during cardiopulmonary resuscitation (CPR) and after return of spontaneous circulation (ROSC) in children.

METHODS

An online survey of CPR practices was designed and sent to healthcare professionals treating children.

RESULTS

A total of 477 healthcare professionals from 46 countries responded to this survey; 92.7% were physicians and 64.2% worked in pediatric intensive care units. Specific CPR guidelines were used by 97.7% of respondents. The respiratory rate most frequently used for children over 12 months was 13 to 20 respirations per minute (rpm) (46% in intubated and 41.8% in non-intubated). For infants under 12 months, the most frequently used respiratory rate was 21 to 30 rpm in intubated patients (37.3%): in non-intubated infants, 13 to 20 rpm (26.5%) and 21 to 30 rpm (26.5%) were used with the same frequency. In North America, the respiratory rate most widely used was 7 to 12 rpm; higher rates (13 to 20 rpm and 21 to 30 rpm) were used in Europe and Latin America (P<0.001). After ROSC, no significant differences in the respiratory rates used were found between the continents. More than 40% of healthcare professionals had a target oxygen saturation below 94%; more than 10% used a target arterial PCO₂ below 35 mmHg and more than 13% above 45 mmHg.

CONCLUSIONS

There is considerable variation in the management of ventilation of children in cardiac arrest, and international recommendations are not being followed in a high percentage of cases.

Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation

AIM

To investigate if the serum biomarkers of cerebral injury, neuron-specific enolase and S100b protein, may classify unfavourable neurological outcome after paediatric cardiac arrest.

METHODS

We performed a retrospective study of neuron-specific enolase and S100b measurements from 95 children treated in our paediatric cardiac intensive care unit after cardiac arrest. Neurological outcome at discharge was evaluated using the paediatric cerebral performance category scale, with unfavourable outcome defined as a change of >1 compared to pre-arrest status or death.

RESULTS

Fifty-eight patients (61.1%) survived to discharge with 48 (50.5%) having a favourable neurological outcome. We observed significantly higher levels of both biomarkers in the unfavourable outcome group at designated time points (neuron-specific enolase at 24, 48, and 72h and S100b at 12, 24, and 48h after cardiac arrest, p<0.05). Receiver operating characteristic areas under the curve for neuron-specific enolase were 0.83, 0.80, and 0.73 at time points 24, 48, and 72h and 0.87, 0.81, and 0.82 for S100b at 12, 24, and 48h after cardiac arrest, respectively. Neuron-specific enolase measurement at 24h after cardiac arrest was an independent predictor of unfavourable outcome in a multivariable analysis.

CONCLUSIONS

Neuron-specific enolase and S100b classify unfavourable neurological outcome in this large paediatric cardiac arrest cohort. Further multi-institutional prospective studies to comprehensively evaluate the diagnostic accuracy of these biomarkers under various clinical conditions and to determine reliable cut-off values in children are warranted.

Paediatric cardiopulmonary resuscitation training program in Latin-America: the RIBEPCI experience

BACKGROUND

To describe the design and to present the results of a paediatric and neonatal cardiopulmonary resuscitation (CPR) training program adapted to Latin-America.

METHODS

A paediatric CPR coordinated training project was set up in several Latin-American countries with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The program was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. Instructors from each country participated in the development of the next group in the following country. Paediatric Basic Life Support (BLS), Paediatric Intermediate (ILS) and Paediatric Advanced (ALS) courses were organized in each country adapted to local characteristics.

RESULTS

Five Paediatric Resuscitation groups were created sequentially in Honduras (2), Guatemala, Dominican Republican and Mexico. During 5 years, 6 instructors courses (94 students), 64 Paediatric BLS Courses (1409 students), 29 Paediatrics ILS courses (626 students) and 89 Paediatric ALS courses (1804 students) were given. At the end of the program all five groups are autonomous and organize their own instructor courses.

CONCLUSIONS

Training of autonomous Paediatric CPR groups with the collaboration and scientific assessment of an expert group is a good model program to develop Paediatric CPR training in low- and middle income countries. Participation of groups of different countries in the educational activities is an important method to establish a cooperation network.

Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource-limited setting

BACKGROUND

Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital.

METHODS

A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed.

RESULTS

Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4).

CONCLUSIONS

PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital's resource-level. Cancer 2017;123:4903-13. © 2017 American Cancer Society.

Incidence and prognosis of nosocomial infection after recovering of cardiac arrest in children

OBJECTIVE

to analyze the incidence of infection in children who have suffered an in-hospital cardiac arrest (CA) and the association with mortality.

METHODS

A retrospective unicenter observational study on a prospective database with children between one month and 16 years old, who have suffered an in-hospital CA was performed. Clinical, analytical and monitorization data, treatment, mortality and cause of death were recorded.

RESULTS

57 children were studied (57.6% males). Recovery of spontaneous circulation (ROSC) was achieved in 50 children (87.7%) and 32 (59.3%) survived. After ROSC, 28 patients (56% of those who achieved ROSC) were diagnosed of infection. There were not significant differences in mortality between patients infected (42.9%) and uninfected (27.3%) p=0.374. Only one died in consequence of a sepsis with multiorganic failure.

CONCLUSIONS

The frequency of infection in children after recovering of a cardiac arrest is high. There were no statistically significant differences in mortality between patients with and without infection after ROSC.

A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival

AIM

Most pediatric in-hospital cardiac arrests (IHCAs) occur in ICUs where invasive hemodynamic monitoring is frequently available. Titrating cardiopulmonary resuscitation (CPR) to the hemodynamic response of the individual improves survival in preclinical models of adult cardiac arrest. The objective of this study was to determine if titrating CPR to systolic blood pressure (SBP) and coronary perfusion pressure (CoPP) in a pediatric porcine model of asphyxia-associated ventricular fibrillation (VF) IHCA would improve survival as compared to traditional CPR.

METHODS

After 7min of asphyxia followed by VF, 4-week-old piglets received either hemodynamic-directed CPR (HD-CPR; compression depth titrated to SBP of 90mmHg and vasopressor administration to maintain CoPP ≥20mmHg); or Standard Care (compression depth 1/3 of the anterior-posterior chest diameter and epinephrine every 4min). All animals received CPR for 10min prior to the first defibrillation attempt. CPR was continued for a maximum of 20min. Protocolized intensive care was provided to all surviving animals for 4h. The primary outcome was 4-h survival.

RESULTS

Survival rate was greater with HD-CPR (12/12) than Standard Care (6/10; p=0.03). CoPP during HD-CPR was higher compared to Standard Care (point estimate +8.1mmHg, CI95: 0.5-15.8mmHg; p=0.04). Chest compression depth was lower with HD-CPR than Standard Care (point estimate -14.0mm, CI95: -9.6 to -18.4mm; p<0.01). Prior to the first defibrillation attempt, more vasopressor doses were administered with HD-CPR vs. Standard Care (median 5 vs. 2; p<0.01).

CONCLUSIONS

Hemodynamic-directed CPR improves short-term survival compared to standard depth-targeted CPR in a porcine model of pediatric asphyxia-associated VF IHCA.

Characteristics and Risk Factors for Mortality in Paediatric In-Hospital Cardiac Events in Singapore: Retrospective Single Centre Experience

Introduction: There is limited data on paediatric resuscitation outcomes in Asia. We aimed to describe outcomes of paediatric in-hospital cardiac arrests (IHCA) and peri-resuscitation factors associated with mortality in our institution. Materials and Methods: Using data from our hospital’s code registry from 2009 to 2014, we analysed all patients younger than 18 years of age with IHCA who required cardiopulmonary resuscitation (CPR). Exposure variables were obtained from clinical demographics, CPR and post-resuscitation data. Outcomes measured were: survival after initial CPR event and survival to hospital discharge. We analysed categorical and continuous variables with Fisher’s exact and Wilcoxon rank-sum tests respectively. Statistical significance was taken as P <0.05. Results: We identified 51 patients in the study period. Median age of patients was 1.9 (interquartile range [IQR]: 0.3, 5.5) years. Twenty-six (51%) patients had bradycardia as the first-recorded rhythm. The most common pre-existing medical condition was respiratory-related (n = 25, 48%). Thirty-eight (75%) achieved sustained return of spontaneous circulation, 24 (47%) survived to paediatric intensive care unit (PICU) discharge and 23 (45%) survived to hospital discharge. Risk factors for hospital mortality included: age, duration of CPR, adrenaline, calcium or bicarbonate administration during CPR, Paediatric Index of Mortality (PIM)-II scores, first recorded post-resuscitation pH and hyperglycaemia within 24 hours of resuscitation. Conclusion: We demonstrated an association between clinical demographics (age, PIM-II scores), CPR variables (duration of CPR and administration of adrenaline, calcium or bicarbonate) and post-resuscitation laboratory results (first recorded pH and hyperglycaemia within 24 hours) with PICU survival. The availability and quality of post-resuscitation care may have implications on survival after paediatric IHCA. Key words: Cardiopulmonary resuscitation, Child, Infant

Different Respiratory Rates during Resuscitation in a Pediatric Animal Model of Asphyxial Cardiac Arrest

Aims

Actual resuscitation guidelines recommend 10 respirations per minute (rpm) for advanced pediatric life support. This respiratory rate (RR) is much lower than what is physiological for children. The aim of this study is to compare changes in ventilation, oxygenation, haemodynamics and return of spontaneous circulation (ROSC) rates with three RR.

Methods

An experimental model of asphyxial cardiac arrest (CA) in 46 piglets (around 9.5 kg) was performed. Resuscitation with three different RR (10, 20 and 30 rpm) was carried out. Haemodynamics and gasometrical data were obtained at 3, 9, 18 and 24 minutes after beginning of resuscitation. Measurements were compared between the three groups.

Results

No statistical differences were found in ROSC rate between the three RR (37.5%, 46.6% and 60% in the 10, 20 and 30 rpm group respectively P = 0.51). 20 and 30 rpm groups had lower PaCO2 values than 10 rpm group at 3 minutes (58 and 55 mmHg vs 75 mmHg P = 0.08). 30 rpm group had higher PaO2 (61 mmHg) at 3 minutes than 20 and 10 rpm groups (53 and 45 mmHg P = 0.05). No significant differences were found in haemodynamics or tissue perfusion between hyperventilated (PaCO2 <30 mmHg), normoventilated (30–50 mmHg) and hypoventilated (>50 mmHg) animals. PaO₂ was significantly higher in hyperventilated (PaO₂ 153 mmHg) than in normoventilated (79 mmHg) and hypoventilated (47 mmHg) piglets (P<0.001).

Conclusions

Our study confirms the hypothesis that higher RR achieves better oxygenation and ventilation without affecting haemodynamics. A higher RR is associated but not significantly with better ROSC rates.

[Multiple organ failure after spontaneous return of circulation in cardiac arrest in children]

OBJECTIVE

To assess the frequency of the multiple organ failure and the prognostic value of multiple organ failure scores in children who have recovered from an in-hospital cardiac arrest.

PATIENTS AND METHODS

A single centre, observational, and retrospective study was conducted on children between 1 month and 16 years old who suffered an in-hospital cardiac arrest and achieved return of spontaneous circulation (ROSC). In the first 24-48hours and between the fifth and the seventh day after ROSC, a record was made of the scores on paediatric severity (PRISM and PIM II) and multiple organ failure scales (PELOD and P-MODS), along with the clinical and analytical data, and including monitoring and treatment, mortality and cause of death.

RESULTS

Of the total of 41 children studied, 70.7% male were male, and the median age was 38 months. The overall mortality during admission was 41.5%, with 14.6% dying in the first 48hours, and 7.6% in the following 3 to 5 days. In the first 48hours, clinical severity and multiple organ failure scores were higher in the patients that died than in survivors (PRISM 29 vs. 21) P=.125, PIM II (26.8% vs. 9.2%) P=.02, PELOD (21 vs. 12) P=.005, and P-MODS (9 vs. 6) P=.001. Between the fifth and seventh day, the scores on the four scales were also higher in patients who died, but only those of the PELOD (20.5 vs. 11) p=.002 and P-MODS (6.5 vs. 3) P=.003 reached statistical significance.

CONCLUSIONS

Mortality in children after return of spontaneous circulation after cardiac arrest is high. The multiple organ failure after return of spontaneous circulation after cardiac arrest in children is associated with increased mortality.

Receipt of Life-Sustaining Treatments for Taiwanese Pediatric Patients Who Died of Cancer in 2001 to 2010: A Retrospective Cohort Study

Aggressive life-sustaining treatments have the potential to be continued beyond benefit, but have seldom been systematically/nationally explored in pediatric cancer patients. Furthermore, factors predisposing children dying of cancer to receive life-sustaining treatments at end of life (EOL) have never been investigated in a population-based study. This population-based study explored determinants of receiving life-sustaining treatments in pediatric cancer patients' last month of life. For this retrospective cohort study, we used administrative data on 1603 Taiwanese pediatric cancer patients who died in 2001 to 2010. Individual patient-level data were linked with encrypted identification numbers from the National Register of Deaths Database, Cancer Registration System database, National Health Insurance claims datasets, and Database of Medical Care Institutions Status. Life-sustaining treatments included intensive care unit (ICU) care, cardiopulmonary resuscitation (CPR), and mechanical ventilation. Associations of patient, physician, hospital, and regional factors with receiving ICU care, CPR, and mechanical ventilation in the last month of life were evaluated by multilevel generalized linear mixed models. In their last month of life, 22.89%, 46.48%, and 61.45% of pediatric cancer patients received CPR, mechanical ventilation, and ICU care, respectively, with no significant decreasing trends from 2001 to 2010. Patients were more likely to receive all three identified life-sustaining treatments at EOL if they were diagnosed with a hematologic malignancy or a localized disease, died within 1 year of diagnosis, and received care from a pediatrician. Receipt of ICU care or mechanical ventilation increased with increasing EOL-care intensity of patients' primary hospital, whereas use of mechanical ventilation decreased with increasing quartile of hospice beds in the patients' primary hospital region. Taiwanese pediatric cancer patients received aggressive life-sustaining treatments in the month before death. Healthcare policies and interventions should aim to help pediatricians treating at-risk pediatric cancer patients and hospitals with a tendency to provide aggressive EOL treatments to avoid the expense of life-sustaining treatments when chance of recovery is remote and to devote resources to care that produces the greatest benefits for children, parents, and society.