Cardiopulmonary resuscitation in hospitalized infants

Complex end-of-life decision-making during neonatal retrieval: A retrospective cohort study

AIM

The aim of this study was to compare patients referred to our retrieval service who were palliated before transfer, versus those transferred who were palliated within 7 days of birth.

METHODS

We conducted a retrospective chart review of infants referred to our neonatal retrieval service between 1 December 2015 and 31 March 2022 who died during retrieval or within 7 days of referral. Demographic and clinical data were collected from the service database and electronic medical records.

RESULTS

Data on 60 infants were analysed; 25 (42%) infants were not transported and were palliated at the referring hospital, 35 (58%) infants were transported and later palliated at the accepting hospital. The most common primary diagnoses were prematurity (42%) and hypoxemic ischemic encephalopathy (HIE) (42%). Infants palliated at the referring hospital were more likely than those transported and later palliated to require resuscitation including chest compressions (52% vs. 23%, P = 0.02), management for hypotension (72% vs. 20%, P < 0.001) and management for pneumothorax (28% vs. 0%, P = 0.001) and less likely to require management for seizures (8% vs. 43%, P = 0.003).

CONCLUSIONS

Palliation at the referring hospital should be considered as an option when escalating care is predicted to not affect outcome. In this cohort the infants least likely to be transported required significant management during stabilisation. Determining the infants for whom transport is non-beneficial remains difficult.

Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics

Between 0.25% and 3% of admissions to the NICU, PICU, and PCICU receive cardiopulmonary resuscitation (CPR). Most CPR events occur in patients <1 year old. The incidence of CPR is 10 times higher in the NICU than at birth. Therefore, optimizing the approach to CPR in hospitalized neonates and infants is important. At birth, the resuscitation of newborns is performed according to neonatal resuscitation guidelines. In older infants and children, resuscitation is performed according to pediatric resuscitation guidelines. Neonatal and pediatric guidelines differ in several important ways. There are no published recommendations to guide the transition from neonatal to pediatric guidelines. Therefore, hospitalized neonates and infants can be resuscitated using neonatal guidelines, pediatric guidelines, or a hybrid approach. This report summarizes the current neonatal and pediatric resuscitation guidelines, considers how to apply them to hospitalized neonates and infants, and identifies knowledge gaps and future priorities. The lack of strong scientific data makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines. Therefore, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice in a given location or situation, considering local circumstances, health care team preferences, and resource limitations.

Use of eye-tracking to evaluate human factors in accessing neonatal resuscitation equipment and medications for advanced resuscitation: A simulation study

Introduction

Emergency neonatal resuscitation equipment is often organized into "code carts". Simulation studies previously examined human factors of neonatal code carts and equipment; however, visual attention analysis with eye-tracking might further inform equipment design.

Objectives

To evaluate human factors of neonatal resuscitation equipment by: (1) comparing epinephrine preparation speed from adult pre-filled syringe vs. medication vial, (2) comparing equipment retrieval times from two carts and (3) utilizing eye-tracking to study visual attention and user experience.

Methods

We conducted a 2-site randomized cross-over simulation study. Site 1 is a perinatal NICU with carts focused on airway management. Site 2 is a surgical NICU with carts improved with compartments and task-based kits. Participants were fitted with eye-tracking glasses then randomized to prepare two epinephrine doses using two methods, starting with an adult epinephrine prefilled syringe or a multiple access vial. Participants then obtained items for 7 tasks from their local cart. Post-simulation, participants completed surveys and semi-structured interviews while viewing eye-tracked video of their performance. Epinephrine preparation times were compared between the two methods. Equipment retrieval times and survey responses were compared between sites. Eye-tracking was analyzed for areas of interest (AOIs) and gaze shifts between AOIs. Interviews were subject to thematic analysis.

Results

Forty HCPs participated (20/site). It was faster to draw the first epinephrine dose using the medication vial (29.9s vs. 47.6s, p < 0.001). Time to draw the second dose was similar (21.2s vs. 19s, p = 0.563). It was faster to obtain equipment from the Perinatal cart (164.4s v 228.9s, p < 0.027). Participants at both sites found their carts easy to use. Participants looked at many AOIs (54 for Perinatal vs. 76 for Surgical carts, p < 0.001) with 1 gaze shifts/second for both.Themes for epinephrine preparation include: Facilitators and Threats to Performance, and Discrepancies due to Stimulation Conditions. Themes for code carts include: Facilitators and Threats to Performance, Orienting with Prescan, and Suggestions for Improvement. Suggested cart improvements include: adding prompts, task-based grouping, and positioning small equipment more visibly. Task-based kits were welcomed, but more orientation is needed.

Conclusions

Eye-tracked simulations provided human factors assessment of emergency neonatal code carts and epinephrine preparation.

Special consideration in neonatal resuscitation

Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.

Current controversies in neonatal resuscitation

The goal of neonatal bioethics is to help clinicians navigate difficult decisions that arise every day in the care of critically ill newborns. Over the last few decades, there have been vigorous discussions of numerous ethical issues. For some, we have worked out a tentative societal agreement for appropriate responses. Others remain contentious and controversial. They evoke moral distress. In this article, we address some of these unresolved issues including the changing landscape of duration and viability threshold for newborn resuscitation, the issue of borderline of viability and the ethical controversies that arise when each center has its own policies, and some of the challenges that arise in Fetal Care Centers (FCC). Finally, we propose a generalizable model of shared decision making.

Optimal Crash Cart Configuration for a Surgical NICU: Utilizing Human Factors Principles

BACKGROUND

Neonates admitted to cardiac and surgical neonatal intensive care units (NICUs) are at an increased risk of requiring emergency lifesaving interventions that require the use of both Neonatal Resuscitation Program (NRP) and Pediatric Advanced Life Support (PALS) algorithms. Clinicians working within the surgical NICU must be able to access emergency equipment and medications quickly in order to respond to critical situations. A crash cart that integrates human factors principles and supports both the NRP and PALS algorithms is necessary to promote patient safety for this high-risk population.

PURPOSE

A multidisciplinary quality improvement project constructed an optimal crash cart configuration that embedded human factors principles and supported clinical workflow by reflecting both the NRP and the PALS algorithms in an NICU that cares for cardiac and surgical patients.

METHODS

A crash cart working group including frontline NICU staff, simulation experts, and a human factors specialist was formed within a surgical NICU. Human factors principles were utilized to align the organization of the cart with the NRP and PALS algorithms to increase the efficiency and intuitiveness of the cart. The new crash cart configuration was usability tested through simulation, revised on the basis of clinical feedback, and then implemented in a clinical setting. Data were collected following implementation of the new crash cart to validate that the new configuration was viewed as a significant improvement. The Plan-Do-Study-Act cycle was used to make improvements and capture outcome indicators.

RESULTS

Evaluation data collected both during usability simulation testing and in situ within the NICU clinical environment indicated that the revised crash cart scored higher on Likert scale response questions than the previous crash cart.

IMPLICATIONS FOR PRACTICE

Human factors science, in combination with frontline user engagement, should be utilized to create intuitive crash cart configurations, which are then tested in a simulation environment and evaluated in situ in the NICU.

IMPLICATIONS FOR RESEARCH

Further research around crash cart design within NICUs that use multiple lifesaving algorithms would add to the paucity of research around the impact of human factors theory in the utilization of lifesaving equipment and medications within this specific population.

Epidemiology and outcomes of infants after cardiopulmonary resuscitation in the neonatal or pediatric intensive care unit from a national registry

AIM

Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).

METHODS

Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.

RESULTS

Among 3521 infants who received CPR, 2080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 h. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).

CONCLUSION

Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.

Survival of pediatric patients after cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

In-hospital cardiac arrest is a major public health issue. It is a serious condition; most probably end up with death within a few minutes even with corrective measures. However, cardiopulmonary resuscitation is expected to increase the probability of survival and prevent neurological disabilities in patients with cardiac arrest. Having a pooled prevalence of survival to hospital discharge after cardiopulmonary resuscitation is vital to develop strategies targeted to increase probability of survival among patients with cardiac arrest. Therefore, this systematic review and meta-analysis was aimed to assess the pooled prevalence of survival to hospital discharge among pediatric patients who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest.

METHODS

PubMed, Google Scholar, and Cochrane review databases were searched. To have current (five-year) evidence, only studies published in 2016 to 2020 were included. The weighted inverse variance random-effects model at 95%CI was used to estimate the pooled prevalence of survival. Heterogeneity assessment, test of publication bias, and subgroup analyses were also employed accordingly.

RESULTS

Twenty-five articles with a total sample size of 28,479 children were included in the final analysis. The pooled prevalence of survival to hospital discharge was found to be 46% (95% CI = 43.0-50.0%; I2 = 96.7%; p < 0.001). Based on subgroup analysis by "continent" and "income level", lowest prevalence of pooled survival was observed in Asia (six studies; pooled survival =36.0% with 95% CI = 19.01-52.15%; I2 = 97.4%; p < 0.001) and in low and middle income countries (six studies, pooled survival = 34.0% with 95% CI = 17.0-51.0%, I2 = 97.67%, p < 0.001) respectively.

CONCLUSION

Although there was an extremely high heterogeneity among reported results (I2 = 96.7%), in this meta-analysis more than half of pediatric patients (54%) who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest did not survived to hospital discharge. Therefore, developing further strategies and encouraging researches might be crucial.

Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study

BACKGROUND

The reported incidence of cardiopulmonary resuscitation (CPR) in quaternary NICU is approximately 10-times higher than in the delivery room. However, the etiologies and outcomes of CPR in quaternary NICUs are poorly understood. We hypothesized that demographic characteristics, diagnoses, interventions, and arrest etiologies would be associated with survival to discharge after CPR.

METHODS

Multicenter retrospective cohort study of four quaternary NICUs over six years (2011-2016). Demographics, resuscitation event data, and post-arrest outcomes were analyzed. The primary outcome was survival to discharge.

RESULTS

Of 17,358 patients admitted to four NICUs, 200 (1.1%) experienced a CPR event, and 45.5% of those survived to discharge. Acute respiratory compromise leading to cardiopulmonary arrest occurred in 182 (91%) of the CPR events. Most neonates requiring CPR were on mechanical ventilation (79%) and had central venous access (90%) at the time of arrest. Treatments at the time of the arrest associated with decreased survival to discharge included mechanical ventilation, antibiotics, or vasopressor therapy (p < 0.01). Etiologies of arrest associated with decreased survival to discharge included multisystem organ failure, septic shock, and pneumothorax (p < 0.05). Longer duration of CPR was associated with decreased survival to discharge. The odds of surviving to discharge decreased for infants who had a primarily cardiac arrest and for infants who received epinephrine during the arrest.

CONCLUSION

Approximately 1% of neonates admitted to quaternary NICUs require CPR. The most common etiology of arrest is acute respiratory compromise on a ventilator. CPR events with respiratory etiology have a favorable outcome as compared to non-respiratory causes.

The Characteristics and Outcomes of Cardiopulmonary Resuscitation within the Neonatal Intensive Care Unit Based on Gestational Age and Unit Level of Care

OBJECTIVES

This study aimed to describe the variation of in-neonatal intensive care unit (NICU) cardiopulmonary resuscitation (CPR) characteristics and outcomes across different gestational ages and levels of NICU care.

STUDY DESIGN

This is a retrospective cohort study of in-NICU CPR events across 10 NICUs in San Antonio, TX from 2012 through 2017.

RESULTS

We identified 140 patients experiencing a total of 210 in-NICU CPR events. CPR was performed in 0.23% of Level III and 0.85% of Level IV NICU admissions. Gestational age was inversely related to CPR incidence. The median age at in-NICU CPR was lower for preterm versus term infants (6 vs. 28 days, p = 0.002). With regression modeling, each added minute of chest compression decreased the odds of return to spontaneous circulation by 11%.

CONCLUSION

In-NICU CPR incidence rises with decreasing gestational age and increasing level of NICU care. The rate of return of spontaneous circulation decreases significantly with increasing duration of chest compressions. Further study is needed to identify patient factors associated with adverse outcome.

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units

OBJECTIVE

To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs).

STUDY DESIGN

We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation.

RESULTS

Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death.

CONCLUSIONS

From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.