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Chamberlain G, Gupta R, Lobos AT. Pediatic code blue event anaylsis: Performance of non-acute health-care providers. MEDICAL EDUCATION ONLINE 2022; 27:2106811. [PMID: 35912470 PMCID: PMC9347468 DOI: 10.1080/10872981.2022.2106811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 06/15/2023]
Abstract
In-hospital pediatric cardiopulmonary arrest is rare. With more than 50% of patients not surviving to discharge following cardiopulmonary arrest, it is important that health-care providers (HCPs) respond appropriately to deteriorating patients. Our study evaluated the performance of basic life support skills using non-acute HCPs during pediatric inpatient resuscitation events. We conducted a retrospective chart review of all code blue team (CBT) activations in non-acute care areas of a tertiary care children's hospital from 2008 to 2017. The main outcomes were frequency of life support algorithmic assessments and interventions (critical actions) performed by non-acute HCPs prior to the arrival of CBT. CBT activation and outcome data were summarized descriptively. Logistic regression was used to assess for an association of outcomes with the presence of established leadership. A total of 60 CBT activations were retrieved, 48 of which had data available on isolated non-acute HCP performance. Most children (93%) survived to discharge. Critical action performance review revealed that an airway, breathing and pulse assessment was documented to have occurred in 33%, 69% and 29% of cases, respectively. A full primary assessment was documented in 6% of cases. The presence of established leadership was associated with the performance of a partial ABC assessment. Our results suggest that resuscitation performance of pediatric inpatient non-acute HCPs often does not adhere to standard life support guidelines. These results highlight the need to reconsider the current approaches used for non-acute HCP resuscitation training.
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Affiliation(s)
| | - Ronish Gupta
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- School of Education, Johns Hopkins University, Baltimore, MD, USA
| | - Anna-Theresa Lobos
- Division of Critical Care, Department of Pediatrics, CHEO, Ottawa, Ontario, Canada
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Calcium Administration During Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest in Children With Heart Disease Is Associated With Worse Survival-A Report From the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry. Pediatr Crit Care Med 2022; 23:860-871. [PMID: 35894607 DOI: 10.1097/pcc.0000000000003040] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES IV calcium administration during cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) is associated with worse survival. We evaluated survival to hospital discharge in children with heart disease (HD), where calcium is more frequently administered during CPR. DESIGN Retrospective study of a multicenter registry database. SETTING Data reported to the American Heart Association's (AHA) Get With The Guidelines-Resuscitation registry. PATIENTS Children younger than 18 years with HD experiencing an index IHCA event requiring CPR between January 2000 and January 2019. Using propensity score matching (PSM), we selected matched cohorts of children receiving and not receiving IV calcium during CPR and compared the primary outcome of survival to hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 4,556 children with HD experiencing IHCA. Calcium was administered in 1,986 (44%), more frequently in children younger than 1 year old (65% vs 35%; p < 0.001) and surgical cardiac (SC) compared with medical cardiac patients (51% vs 36%; p < 0.001). Calcium administration during CPR was associated with longer duration CPR (median 27 min [interquartile range (IQR): 10-50 min] vs 5 min [IQR, 2-16 min]; p < 0.001) and more frequent extracorporeal-CPR deployment (25% vs 8%; p < 0.001). In the PSM cohort, those receiving calcium had decreased survival to hospital discharge (39% vs 46%; p = 0.02) compared with those not receiving calcium. In a subgroup analysis, decreased discharge survival was only seen in SC cohorts. CONCLUSIONS Calcium administration during CPR for children with HD experiencing IHCA is common and is associated with worse survival. Administration of calcium during CPR in children with HD should be restricted to specific indications as recommended by the AHA CPR guidelines.
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Klinische Notfallausbildung in der Pädiatrie. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01250-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Zusammenfassung
Hintergrund und Fragestellung
Die klinische Notfallausbildung von WeiterbildungsassistentInnen (WBA) ist uneinheitlich. Pädiatrische Reanimationen sind seltener erforderlich als Reanimationen erwachsener Patienten; erstversorgende Teams treffen ad hoc zusammen und stehen initial oft unter der Leitung junger ÄrztInnen. Die Teamzusammenarbeit ist von besonderer Bedeutung für das Überleben und Outcome der PatientInnen.
Ziel der Arbeit
Die subjektive Sicherheit im Notfallmanagement der WBA in sächsischen Kinderkliniken sollte ermittelt werden.
Material und Methoden
Hierzu wurde ein Erhebungsbogen für eine webbasierte Umfrage entwickelt, die folgende Aspekte umfasste: Berufserfahrung, innerhäusliche Ausbildung, Erfahrung und gefühlte Sicherheit im Management von Notfallsituationen.
Ergebnisse
Von geschätzten 230 Pädiatrie-WBA in Sachsen antworteten 66 (ca. 29 %). Es fühlten sich 14 % der WBA gut (3 % sehr gut) für Notfallsituationen ausgebildet, wobei 11 % auch eine (sehr) gute Sicherheit in der Teamleitung von Notfällen angaben. Demgegenüber hatten 42 % bereits eine oder mehrere Reanimationen als TeamleiterInnen erlebt. Von den befragten WBA gaben 42 % an, in den letzten 12 Monaten kein Simulationstraining absolviert zu haben; die Mehrzahl der WBA wünscht sich jedoch mehr Training.
Schlussfolgerung
Die Ergebnisse zeigen, dass sich viele WBA in sächsischen Kinderkliniken im Notfallmanagement unzureichend ausgebildet fühlen. Es besteht eine deutliche Diskrepanz zwischen den tatsächlichen Anforderungen und der innerklinischen Ausbildung.
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Hemodynamic Patterns Before Inhospital Cardiac Arrest in Critically Ill Children: An Exploratory Study. Crit Care Explor 2021; 3:e0443. [PMID: 34151279 PMCID: PMC8205221 DOI: 10.1097/cce.0000000000000443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To characterize prearrest hemodynamic trajectories of children suffering inhospital cardiac arrest. DESIGN: Exploratory retrospective analysis of arterial blood pressure and electrocardiogram waveforms. SETTING: PICU and cardiac critical care unit in a tertiary-care children’s hospital. PATIENTS: Twenty-seven children with invasive blood pressure monitoring who suffered a total of 31 inhospital cardiac arrest events between June 2017 and June 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed changes in cardiac output, systemic vascular resistance, stroke volume, and heart rate derived from arterial blood pressure waveforms using three previously described estimation methods. We observed substantial prearrest drops in cardiac output (population median declines of 65–84% depending on estimation method) in all patients in the 10 minutes preceding inhospital cardiac arrest. Most patients’ mean arterial blood pressure also decreased, but this was not universal. We identified three hemodynamic patterns preceding inhospital cardiac arrest: subacute pulseless arrest (n = 18), acute pulseless arrest (n = 7), and bradycardic arrest (n = 6). Acute pulseless arrest events decompensated within seconds, whereas bradycardic and subacute pulseless arrest events deteriorated over several minutes. In the subacute and acute pulseless arrest groups, decreases in cardiac output were primarily due to declines in stroke volume, whereas in the bradycardic group, the decreases were primarily due to declines in heart rate. CONCLUSIONS: Critically ill children exhibit distinct physiologic behaviors prior to inhospital cardiac arrest. All events showed substantial declines in cardiac output shortly before inhospital cardiac arrest. We describe three distinct prearrest patterns with varying rates of decline and varying contributions of heart rate and stroke volume changes to the fall in cardiac output. Our findings suggest that monitoring changes in arterial blood pressure waveform-derived heart rate, pulse pressure, cardiac output, and systemic vascular resistance estimates could improve early detection of inhospital cardiac arrest by up to several minutes. Further study is necessary to verify the patterns witnessed in our cohort as a step toward patient rather than provider-centered definitions of inhospital cardiac arrest.
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The Prognostic Value of Early Amplitude-Integrated Electroencephalography Monitoring After Pediatric Cardiac Arrest. Pediatr Crit Care Med 2020; 21:248-255. [PMID: 31688714 DOI: 10.1097/pcc.0000000000002171] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess the ability of amplitude-integrated electroencephalography monitoring within 24 hours of the return of spontaneous circulation to prognosticate neurologic outcomes in children following cardiac arrest DESIGN:: Retrospective review of prospectively recorded data. An amplitude-integrated electroencephalography background score was calculated according to background activity during the first 24 hours after return of spontaneous circulation, a higher score correlating with more impaired background activity. The primary endpoint was the neurologic outcome as defined by the Pediatric Cerebral Performance Category at PICU discharge (Pediatric Cerebral Performance Category 1-3: a good neurologic outcome; Pediatric Cerebral Performance Category 4-6: a poor neurologic outcome). SETTING A referral PICU. PATIENTS Thirty children with a median age of 10 months (2-38 mo) and a male/female sex ratio of 1.3 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighteen patients were assigned to the favorable outcome group and 12 to the unfavorable outcome group. The median time between return of spontaneous circulation and amplitude-integrated electroencephalography initiation was 4 hours (3-9 hr). The amplitude-integrated electroencephalography score within 24 hours after return of spontaneous circulation was significantly higher in the children with poor outcomes compared with those with good outcomes (12 ± 4 vs 25 ± 8; p < 0.001). Background activity during amplitude-integrated electroencephalography monitoring was able to predict poor neurologic outcomes at PICU discharge, with an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.81-1.00). CONCLUSIONS Early amplitude-integrated electroencephalography monitoring may help predict poor neurologic outcomes in children within 24 hours following cardiac arrest.
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Simeone S, Platone N, Serra N, Assanta N, Guillari A, Rea T, Pucciarelli G, Da Valle P, Gargiulo G, Baratta S, McLellan M. Cardiac Children's Hospital Early Warning Score: Italian Validation. J Pediatr Nurs 2020; 51:e21-e26. [PMID: 31262605 DOI: 10.1016/j.pedn.2019.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/PURPOSE The Cardiac Children's Hospital Early Warning Score (C-CHEWS) is an early warning scale used to identify paediatric patients experiencing clinical deterioration which may warrant a transfer to an ICU. However, no studies have tested the C-CHEWS in an Italian paediatric cardiac population. The aims of this study were to translate/back-translate and validate the Italian version of the C-CHEWS and its algorithm. DESIGN AND METHOD Retrospective study. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value were used to evaluate the performance of C-CHEWS. In additions the Cohen's kappa statistic was calculated to evaluate the agreement between patient's status described by C-CHEWS score (≥5) and actual ICU transfer. RESULTS High discrimination was observed for sensitivity (81.5%), specificity (99.6%), accuracy (99.7%), positive predictive value (86.7%), and negative predictive value (99.8%). The Cohen's kappa score was observed to be equal to 0.837 (p-value <0.001) indicating there was excellent significant agreement between a C-CHEWS score ≥ 5 and effective evaluation for patients transfer to an ICU. CONCLUSION The Italian version of the C-CHEWS proved to be a sensitive, specific and reliable tool in the early detection of a physical deterioration of hospitalized paediatric cardiac surgical patients. PRACTICE IMPLICATIONS This tool may help doctors, nurses and all healthcare professionals to promptly recognize and treat clinical deterioration and facilitate urgent transfers to the PICU.
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Affiliation(s)
- Silvio Simeone
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - Nicola Serra
- Public Health Department, Federico II University Hospital, Naples, Italy
| | | | - Assunta Guillari
- Public Health Department, Federico II University Hospital, Naples, Italy
| | - Teresa Rea
- Public Health Department, Federico II University Hospital, Naples, Italy
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | | | - Gianpaolo Gargiulo
- Haematology and HSCT Unit, Federico II University Hospital, Naples, Italy
| | | | - Mary McLellan
- Inpatient Cardiovascular Unit Heart Center Boston Children's Hospital, Boston, USA
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Shakoor A, Pedroso FE, Jacobs SE, Okochi S, Zenilman A, Cheung EW, Middlesworth W. Extracorporeal Cardiopulmonary Resuscitation (ECPR) in Infants and Children: A Single-Center Retrospective Study. World J Pediatr Congenit Heart Surg 2020; 10:582-589. [PMID: 31496406 DOI: 10.1177/2150135119862598] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used to rescue patients with cardiac arrest refractory to conventional therapy, necessitating evaluation of factors that may affect outcomes. METHODS A single-center retrospective review of pediatric patients (<21 years old) who underwent ECPR from January 2010 to November 2017. Comparisons between nonsurvivors and survivors, to decannulation and discharge, were made. Factors associated with survival and rate of complications were examined. RESULTS Seventy patients were supported with ECPR. Forty-nine (70%) patients survived to decannulation and 38 (54%) patients to discharge. There was no statistical difference between baseline characteristics of survivors and nonsurvivors, including age at cannulation, weight (kg), time to cannulation (minutes), and total time on extracorporeal membrane oxygenation (hours). Survivors to discharge had significantly higher pH prior to cannulation compared to nonsurvivors (7.11 ± 0.24 vs 6.97 ± 0.21, P = .01). Of all, 23.2% of patients received renal replacement therapy (RRT), 39.4% had significant bleeding, 22.5% had thrombotic complications, and 68.8% had neurologic injury on imaging studies. A greater number of nonsurvivors received RRT compared to survivors to discharge (35.5% vs 10.8%, P = .02). There were no differences in bleeding or thrombotic complications or radiographically established neurologic injury. CONCLUSIONS Although ECPR effectively increases overall survival, a better characterization of long-term outcomes is needed.
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Affiliation(s)
- Aqsa Shakoor
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Felipe E Pedroso
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Shimon E Jacobs
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Shunpei Okochi
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ariela Zenilman
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
| | - Eva W Cheung
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
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Stotts JR, Lyndon A, Chan GK, Bekmezian A, Rehm RS. Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review. J Pediatr Nurs 2020; 50:59-74. [PMID: 31770679 DOI: 10.1016/j.pedn.2019.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Abstract
PROBLEM Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance. ELIGIBILITY CRITERIA Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals. SAMPLE Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning. CONCLUSIONS Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability. IMPLICATIONS Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.
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Affiliation(s)
- James R Stotts
- Department of Family Health Nursing, University of California, San Francisco, CA, USA; Department of Patient Safety and Regulatory Affairs, UCSF Health, San Francisco, CA, USA.
| | - Audrey Lyndon
- Department of Family Health Nursing, University of California, San Francisco, CA, USA.
| | - Garrett K Chan
- Department of Physiologic Nursing, University of California, San Francisco, CA, USA; Division of Primary Care and Population Health, Stanford School of Medicine, Stanford, CA, USA.
| | - Arpi Bekmezian
- Department of Pediatrics, University of California, San Francisco, CA, USA; San Francisco, CA, USA.
| | - Roberta S Rehm
- Department of Family Health Nursing, University of California, San Francisco, CA, USA.
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The Association of Hospital Rate of Delayed Epinephrine Administration With Survival to Discharge for Pediatric Nonshockable In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2019; 20:405-416. [PMID: 30672841 DOI: 10.1097/pcc.0000000000001863] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the variation of hospital rates of delayed epinephrine administration in pediatric patients with nonshockable in-hospital cardiac arrest, and the association of those rates with event, 24-hour, and overall survival to hospital discharge. DESIGN A retrospective evaluation was performed. Delayed epinephrine was defined as greater than 5 minutes between the time the need for chest compressions was identified and epinephrine was administered. The main outcome was the association of hospital rate of delayed epinephrine administration with survival to hospital discharge. Secondary outcomes were event and 24-hour survival. Evaluation used hierarchical logistic regression and included 13 patient/event-level and seven hospital-level factors. SETTING Hospitals with greater than 6 months data in the American Heart Association's Get With the Guidelines-Resuscitation registry (2000-2016) and greater than or equal to five total pediatric cardiac arrests with nonshockable rhythm. PATIENTS Children less than 18 years old with index nonshockable in-hospital cardiac arrest treated with greater than or equal to one epinephrine dose. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-thousand four-hundred sixty-two patients at 69 hospitals were included: 218 patients (14.9%) had epinephrine delay rates ranging from 0% to 80% of events (median, 15.6%; interquartile range, 7-25%). The median and interquartile range of hospital level delay was 16% (7-25%). Patient/event-level predictors of delayed epinephrine were asystole (odds ratio, 1.54 [95% CI, 1.10-2.16]) and insertion of an endotracheal tube (odds ratio, 1.86 [95% CI, 1.27-2.73]). Hospital size less than 200 compared with greater than or equal to 500 beds (odds ratio, 3.07 [95% CI, 1.22-7.73]) and ICU location (odds ratio, 0.51 [95% CI, 0.36-0.74]) were associated with epinephrine delay rates. After adjustment, increasing quartiles of epinephrine delay were associated with lower patient and hospital-level return of spontaneous circulation (p = 0.019, p = 0.006) and 24-hour survival (p = 0.018, p = 0.002) respectively, but not survival to discharge (p = 0.20, p = 0.24). CONCLUSIONS Delayed epinephrine administration following pediatric nonshockable in-hospital cardiac arrest varies significantly between hospitals. Hospitals with higher rates of delayed epinephrine administration had worse patient- and hospital-level outcomes after adjusting for multiple patient- and hospital-level factors. Delayed epinephrine administration may directly contribute to increased mortality risk and/or may be a marker of unmeasured elements of hospital resuscitation performance.
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Khera R, Tang Y, Girotra S, Nadkarni VM, Link MS, Raymond TT, Guerguerian AM, Berg RA, Chan PS. Pulselessness After Initiation of Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children. Circulation 2019; 140:370-378. [PMID: 31006260 DOI: 10.1161/circulationaha.118.039048] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, their rate of progression to pulseless cardiac arrest despite CPR and the differences in survival compared with initially pulseless arrest are unknown. We examined the prevalence and predictors of survival of children who progress from bradycardia to pulseless in-hospital cardiac arrest despite CPR. METHODS Pediatric patients >30 days and <18 years of age who received CPR at hospitals participating in Get With The Guidelines-Resuscitation during 2000 to 2016 were included. Each CPR event was classified as bradycardia with pulse, bradycardia with subsequent pulselessness, and initial pulseless cardiac arrest. We assessed risk-adjusted rates of survival to hospital discharge using multilevel Poisson regression models. RESULTS Overall, 5592 pediatric patients were treated with CPR, of whom 2799 (50.1%) received CPR for bradycardia with poor perfusion and 2793 (49.9%) for initial pulseless cardiac arrest. Among those with bradycardia, 869 (31.0%, or 15.5% of cohort) became pulseless after a median of 3 minutes of CPR (interquartile range, 1-9 minutes). Rates of survival to discharge were 70.0% (1351 of 1930) for bradycardia with pulse, 30.1% (262 of 869) for bradycardia progressing to pulselessness, and 37.5% (1046 of 2793) for initial pulseless cardiac arrest (P for difference across groups <0.001). Children who became pulseless despite CPR for bradycardia had a 19% lower likelihood (risk ratio, 0.81 [95% CI, 0.70, 0.93]; P=0.004) of surviving to hospital discharge than those who were initially pulseless. Among children who progressed to pulselessness despite CPR for bradycardia, a longer interval between CPR and pulselessness was a predictor of lower survival (reference, <2 minutes; for 2-5 minutes, risk ratio, 0.54 [95% CI, 0.41-0.70]; for >5 minutes, risk ratio, 0.41 [95% CI, 0.32-0.53]). CONCLUSIONS Among hospitalized children in whom CPR is initiated, half have bradycardia with poor perfusion at the initiation of chest compressions, and nearly one-third of these progress to pulseless in-hospital cardiac arrest despite CPR. Survival was significantly lower for children who progress to pulselessness despite CPR compared with those who were initially pulseless. These findings suggest that pediatric patients who lose their pulse despite resuscitation attempts are at particularly high risk and require a renewed focus on postresuscitation care.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., M.S.L.)
| | - Yuanyuan Tang
- Mid-America Heart Institute, Kansas City, MO (Y.T., P.S.C.)
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.)
| | - Vinay M Nadkarni
- Children's Hospital of Philadelphia, PA (V.M.N., R.A.B.).,Department of Anesthesiology and Critical Care Medicine and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (V.M.N., R.A.B.)
| | - Mark S Link
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., M.S.L.)
| | - Tia T Raymond
- Division of Pediatric Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX (T.T.R.)
| | | | - Robert A Berg
- Children's Hospital of Philadelphia, PA (V.M.N., R.A.B.).,Department of Anesthesiology and Critical Care Medicine and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (V.M.N., R.A.B.)
| | - Paul S Chan
- Mid-America Heart Institute, Kansas City, MO (Y.T., P.S.C.).,Division of Cardiology, Department of Internal Medicine, University of Missouri-Kansas City (P.S.C.)
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Cardiac Arrest in the Pediatric Cardiac ICU: Is Medical Congenital Heart Disease a Predictor of Survival? Pediatr Crit Care Med 2019; 20:233-242. [PMID: 30785870 DOI: 10.1097/pcc.0000000000001810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children with medical cardiac disease experience poorer survival to hospital discharge after cardiopulmonary arrest compared with children with surgical cardiac disease. Limited literature exists describing epidemiology and factors associated with mortality in this heterogeneous population. We aim to evaluate the clinical characteristics and outcomes after cardiopulmonary arrest in medical cardiac patients. DESIGN We performed a retrospective review of pediatric cardiac patients who underwent cardiopulmonary resuscitation in a tertiary care cardiac ICU. Surgical cardiac patients underwent cardiac surgery immediately prior to ICU admission. Nonsurgical cardiac patients were divided into two groups based on the presence of congenital heart disease: congenital heart disease medical or noncongenital heart disease medical. Clinical and outcome variables were collected. Primary outcome was survival to hospital discharge. SETTINGS Texas Children's Hospital cardiac ICU. PATIENTS Patients admitted to Texas Children's Hospital cardiac ICU between January 2011 and December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 150 cardiopulmonary arrest events reviewed, 90 index events were included (46 surgical, 26 congenital heart disease medical, and 18 noncongenital heart disease medical). There was no difference in primary outcome among the three groups. The absence of an epinephrine infusion precardiopulmonary arrest was associated with increased odds of survival in the congenital heart disease medical group (p = 0.03). Noncongenital heart disease medical patients experienced pulseless ventricular tachycardia/ventricular fibrillation more frequently than congenital heart disease medical patients (p = 0.02). Congenital heart disease medical patients had trends toward longer cardiac arrest durations, higher prevalence of neurologic sequelae postcardiopulmonary arrest, and higher mortality when extracorporeal support at cardiopulmonary resuscitation was employed. CONCLUSIONS Although trends in first documented rhythm, neurologic sequelae, and inotropic support prior to cardiopulmonary arrest were noted between groups, no significant differences in survival after cardiac arrest were seen. Larger scale studies are needed to better describe factors associated with cardiopulmonary arrest as well as survival in heterogeneous medical cardiac populations.
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Al-Thubaity D, Williamson S, Leavey R, Tume LN. Newly qualified Saudi nurses' ability to recognize the deteriorating child in hospital. Nurs Crit Care 2018; 24:263-267. [PMID: 30004156 DOI: 10.1111/nicc.12356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 04/08/2018] [Accepted: 04/20/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is recognized that nurses' failure to recognize and respond promptly to deterioration in children's physiological status can result in increased morbidity and mortality. AIM The aim of this study was to explore the ability of Saudi-educated, newly qualified nurses, working in paediatric wards, to recognize children's deterioration. METHODS A pilot study was carried out to assess nurses' responses to three clinical vignettes (deteriorating child, improving child and ambiguous scenarios). The nurses' ability to make a correct identification was captured using a 'Think Aloud' approach and quantified using a visual analogue scale. RESULTS Twenty-seven nurses in two geographical regions in Saudi Arabia participated. Only half the nurses (51·8%) correctly identified the deteriorating child vignette. Of those who could not, 37% were unsure and 11% responded incorrectly. No nurses correctly identified all three vignettes, and four nurses (15%) responded incorrectly to all vignettes. CONCLUSIONS The recognition of the deteriorating child is complex, and even in non-stressful simulated scenarios using vignettes, many newly qualified nurses working with children failed to recognize clear signs of deterioration. A focused (culturally specific) educational intervention is being developed to target this, taking into account Saudi nurses' perceived education and training needs. RELEVANCE TO CLINICAL PRACTICE Newly qualified nurses working in paediatric wards frequently find it difficult to identify the deteriorating child.
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Lin Y, Cheng A, Grant VJ, Currie GR, Hecker KG. Improving CPR quality with distributed practice and real-time feedback in pediatric healthcare providers - A randomized controlled trial. Resuscitation 2018; 130:6-12. [PMID: 29944894 DOI: 10.1016/j.resuscitation.2018.06.025] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Guideline compliant CPR is associated with improved survival for patients with cardiac arrest. Conventional Basic Life Support (BLS) training results in suboptimal CPR competency and skill retention. We aimed to compare the effectiveness of distributed CPR training with real-time feedback to conventional BLS training for CPR skills in pediatric healthcare providers. METHODS Healthcare providers were randomized into receiving annual BLS training (control) or distributed training with real-time feedback (intervention). The intervention group was asked to practice CPR for 2 min on mannequins while receiving real-time CPR feedback, at least once per month. Control group participants were not asked to practice CPR during the study period. Excellent CPR was defined as 90% guideline-compliance for depth, rate and recoil of chest compressions. CPR performance of participants was assessed (on infant and adult-sized mannequins) every 3 months for a duration of 12 months. CPR performance was compared between the 2 groups. RESULTS A total of 87 healthcare providers were included in the analyses (control n = 41, intervention n = 46). Baseline assessment showed no significant difference in CPR performance across the 2 groups. The intervention group has a significantly greater proportion of participants with excellent CPR compared with the control group on an adult sized mannequin (14.6% vs. 54.3%, p < 0.001) and infant-sized mannequin (19.5% vs. 71.7%, p < 0.001) at the end of the study. In the intervention group, all CPR metrics except infant depth were improved and retained over the course of the study. CONCLUSION Distributed CPR training with real-time feedback improves the compliance of AHA guidelines of quality of CPR.
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Affiliation(s)
- Yiqun Lin
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, Department of Community Health Sciences, University of Calgary, 2888 Shaganappi Trail NW, Calgary, Alberta, T3B 6A8, Canada.
| | - Adam Cheng
- University of Calgary, KidSIM-ASPIRE Research Program, Section of Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta, T3B 6A8, Canada.
| | - Vincent J Grant
- University of Calgary, KidSIM-ASPIRE Research Program, Section of Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta, T3B 6A8, Canada.
| | - Gillian R Currie
- University of Calgary, Department of Community Health Sciences, Department of Pediatrics, University of Calgary, HRIC Building, 3280 Hospital Drive NW, Calgary, Alberta, T3N 4Z6, Canada.
| | - Kent G Hecker
- University of Calgary, Department of Veterinary Clinic and Diagnostic Sciences, Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4A6, Canada.
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Derivation and Internal Validation of a Mortality Prediction Tool for Initial Survivors of Pediatric In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2018; 19:186-195. [PMID: 29239980 PMCID: PMC5834369 DOI: 10.1097/pcc.0000000000001416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To develop a clinical prediction score for predicting mortality in children following return of spontaneous circulation after in-hospital cardiac arrest. DESIGN Observational study using prospectively collected data. SETTING This was an analysis using data from the Get With The Guidelines-Resuscitation registry between January 2000 and December 2015. PATIENTS Pediatric patients (< 18 yr old) who achieved return of spontaneous circulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality. Patients were divided into a derivation (3/4) and validation (1/4) cohort. A prediction score was developed using a multivariable logistic regression model with backward selection. Patient and event characteristics for the derivation cohort (n = 3,893) and validation cohort (n = 1,297) were similar. Seventeen variables associated with the outcome remained in the final reduced model after backward elimination. Predictors of in-hospital mortality included age, illness category, pre-event characteristics, arrest location, day of the week, nonshockable pulseless rhythm, duration of chest compressions, and interventions in place at time of arrest. The C-statistic for the final score was 0.77 (95% CI, 0.75-0.78) in the derivation cohort and 0.77 (95% CI, 0.74-0.79) in the validation cohort. The expected versus observed mortality plot indicated good calibration in both the derivation and validation cohorts. The score showed a stepwise increase in mortality with an observed mortality of less than 15% for scores 0-9 and greater than 80% for scores greater than or equal to 25. The model also performed well for neurologic outcome and in sensitivity analyses for events within the past 5 years and for patients with or without a pulse at the onset of chest compressions. CONCLUSIONS We developed and internally validated a prediction score for initial survivors of pediatric in-hospital cardiac arrest. This prediction score may be useful for prognostication following cardiac arrest, stratifying patients for research, and guiding quality improvement initiatives.
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Lin Y, Wan B, Belanger C, Hecker K, Gilfoyle E, Davidson J, Cheng A. Reducing the impact of intensive care unit mattress compressibility during CPR: a simulation-based study. Adv Simul (Lond) 2017; 2:22. [PMID: 29450023 PMCID: PMC5806490 DOI: 10.1186/s41077-017-0057-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The depth of chest compression (CC) during cardiac arrest is associated with patient survival and good neurological outcomes. Previous studies showed that mattress compression can alter the amount of CCs given with adequate depth. We aim to quantify the amount of mattress compressibility on two types of ICU mattresses and explore the effect of memory foam mattress use and a backboard on mattress compression depth and effect of feedback source on effective compression depth. METHODS The study utilizes a cross-sectional self-control study design. Participants working in the pediatric intensive care unit (PICU) performed 1 min of CC on a manikin in each of the following four conditions: (i) typical ICU mattress; (ii) typical ICU mattress with a CPR backboard; (iii) memory foam ICU mattress; and (iv) memory foam ICU mattress with a CPR backboard, using two different sources of real-time feedback: (a) external accelerometer sensor device measuring total compression depth and (b) internal light sensor measuring effective compression depth only. CPR quality was concurrently measured by these two devices. The differences of the two measures (mattress compression depth) were summarized and compared using multilevel linear regression models. Effective compression depths with different sources of feedback were compared with a multilevel linear regression model. RESULTS The mean mattress compression depth varied from 24.6 to 47.7 mm, with percentage of depletion from 31.2 to 47.5%. Both use of memory foam mattress (mean difference, MD 11.7 mm, 95%CI 4.8-18.5 mm) and use of backboard (MD 11.6 mm, 95% CI 9.0-14.3 mm) significantly minimized the mattress compressibility. Use of internal light sensor as source of feedback improved effective CC depth by 7-14 mm, compared with external accelerometer sensor. CONCLUSION Use of a memory foam mattress and CPR backboard minimizes mattress compressibility, but depletion of compression depth is still substantial. A feedback device measuring sternum-to-spine displacement can significantly improve effective compression depth on a mattress. TRIAL REGISTRATION Not applicable. This is a mannequin-based simulation research.
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Affiliation(s)
- Yiqun Lin
- KidSIM-ASPIRE Simulation Research Program, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
| | - Brandi Wan
- Faculty of Nursing, University of British Columbia, T201-2211 Westbrook Mall, Vancouver, BC V6T 2B5 Canada
| | - Claudia Belanger
- Faculty of Kinesiology, Queens University, 99 University Ave, Kingston, ON K7L 3N6 Canada
| | - Kent Hecker
- Department of Community Health Sciences, Cumming School of Medicine and Faculty of Veterinary Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1 Canada
| | - Elaine Gilfoyle
- Department of Pediatrics, Section of Critical Care, Cumming School of Medicine, Alberta Children’s Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
| | - Jennifer Davidson
- Division of Emergency Medicine, Department of Pediatrics and KidSIM-ASPIRE Research Program, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
| | - Adam Cheng
- Division of Emergency Medicine, Department of Pediatrics and KidSIM-ASPIRE Research Program, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
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Validation of the Children's Hospital Early Warning System for Critical Deterioration Recognition. J Pediatr Nurs 2017; 32:52-58. [PMID: 27823915 DOI: 10.1016/j.pedn.2016.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Early warning scores, such as the Children's Hospital Early Warning Score (CHEWS), are used by hospitals to identify patients at risk for critical deterioration and trigger clinicians to intervene and prevent further deterioration. This study's objectives were to validate the CHEWS and to compare the CHEWS to the previously validated Brighton Pediatric Early Warning Score (PEWS) for early detection of critical deterioration in hospitalized, non-cardiac patients at a pediatric hospital. DESIGN AND METHODS A retrospective cohort study reviewed medical and surgical patients at a quaternary academic pediatric hospital. CHEWS scores and abstracted PEWS scores were obtained on cases (n=360) and a randomly selected comparison sample (n=776). Specificity, sensitivity, area under the receiver-operating characteristic curves (AUROC) and early warning times were calculated for both scoring tools. RESULTS The AUROC for CHEWS was 0.902 compared to 0.798 for PEWS (p<0.001). Sensitivity for scores ≥3 was 91.4% for CHEWS and 73.6% for PEWS with specificity of 67.8% for CHEWS and 88.5% for PEWS. Sensitivity for scores ≥5 was 75.6% for CHEWS and 38.9% for PEWS with specificity of 88.5% for CHEWS and 93.9% for PEWS. The early warning time from critical score (≥5) to critical deterioration was 3.8h for CHEWS versus 0.6h for PEWS (p<0.001). CONCLUSION The CHEWS system demonstrated higher discrimination, higher sensitivity and longer early warning time than the PEWS for identifying children at risk for critical deterioration.
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Validation of a Pediatric Early Warning Score in Hospitalized Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients. Pediatr Crit Care Med 2016; 17:e146-53. [PMID: 26914628 DOI: 10.1097/pcc.0000000000000662] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the correlation of a Pediatric Early Warning Score with unplanned transfer to the PICU in hospitalized oncology and hematopoietic stem cell transplant patients. DESIGN We performed a retrospective matched case-control study, comparing the highest documented Pediatric Early Warning Score within 24 hours prior to unplanned PICU transfers in hospitalized pediatric oncology and hematopoietic stem cell transplant patients between September 2011 and December 2013. Controls were patients who remained on the inpatient unit and were matched 2:1 using age, condition (oncology vs hematopoietic stem cell transplant), and length of hospital stay. Pediatric Early Warning Scores were documented by nursing staff at least every 4 hours as part of routine care. Need for transfer was determined by a PICU physician called to evaluate the patient. SETTING A large tertiary/quaternary free-standing academic children's hospital. PATIENTS One hundred ten hospitalized pediatric oncology patients (42 oncology, 68 hematopoietic stem cell transplant) requiring unplanned PICU transfer and 220 matched controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Using the highest score in the 24 hours prior to transfer for cases and a matched time period for controls, the Pediatric Early Warning Score was highly correlated with the need for PICU transfer overall (area under the receiver operating characteristic = 0.96), and in the oncology and hematopoietic stem cell transplant groups individually (area under the receiver operating characteristic = 0.95 and 0.96, respectively). The difference in Pediatric Early Warning Score results between the cases and controls was noted as early as 24 hours prior to PICU admission. Seventeen patients died (15.4%). Patients with higher Pediatric Early Warning Scores prior to transfer had increased PICU mortality (p = 0.028) and length of stay (p = 0.004). CONCLUSIONS We demonstrate that our institution's Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Scores as a method of early identification of clinical deterioration in this high-risk population.
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Lurie KG, Nemergut EC, Yannopoulos D, Sweeney M. The Physiology of Cardiopulmonary Resuscitation. Anesth Analg 2016; 122:767-783. [DOI: 10.1213/ane.0000000000000926] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
OBJECTIVES To build and test cardiac arrest prediction models in a PICU, using time series analysis as input, and to measure changes in prediction accuracy attributable to different classes of time series data. DESIGN Retrospective cohort study. SETTING Thirty-one bed academic PICU that provides care for medical and general surgical (not congenital heart surgery) patients. SUBJECTS Patients experiencing a cardiac arrest in the PICU and requiring external cardiac massage for at least 2 minutes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred three cases of cardiac arrest and 109 control cases were used to prepare a baseline dataset that consisted of 1,025 variables in four data classes: multivariate, raw time series, clinical calculations, and time series trend analysis. We trained 20 arrest prediction models using a matrix of five feature sets (combinations of data classes) with four modeling algorithms: linear regression, decision tree, neural network, and support vector machine. The reference model (multivariate data with regression algorithm) had an accuracy of 78% and 87% area under the receiver operating characteristic curve. The best model (multivariate + trend analysis data with support vector machine algorithm) had an accuracy of 94% and 98% area under the receiver operating characteristic curve. CONCLUSIONS Cardiac arrest predictions based on a traditional model built with multivariate data and a regression algorithm misclassified cases 3.7 times more frequently than predictions that included time series trend analysis and built with a support vector machine algorithm. Although the final model lacks the specificity necessary for clinical application, we have demonstrated how information from time series data can be used to increase the accuracy of clinical prediction models.
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Kalaniti K, Schmölzer GM, McNamara PJ. Neonatal resuscitation beyond the delivery room - does one protocol fit all? Acta Paediatr 2015; 104:971-3. [PMID: 26174225 DOI: 10.1111/apa.13116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/07/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Kaarthigeyan Kalaniti
- Division of Neonatology; Department of Pediatrics; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation; Neonatal Research Unit; Royal Alexandria Hospital; Edmonton AB Canada
- Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | - Patrick J McNamara
- Division of Neonatology; Department of Pediatrics; Hospital for Sick Children; University of Toronto; Toronto ON Canada
- Department of Physiology & Experimental Medicine Program; Hospital for Sick Children; Toronto ON Canada
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Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA 2015; 314:802-10. [PMID: 26305650 PMCID: PMC6191294 DOI: 10.1001/jama.2015.9678] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. OBJECTIVE To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. DESIGN, SETTING AND PARTICIPANTS We performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort. EXPOSURE Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale. RESULTS Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01). CONCLUSIONS AND RELEVANCE Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.
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Affiliation(s)
- Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Katherine M Berg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brian Z Saindon
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joseph M Massaro
- Harvard Clinical Research Institute, Boston, Massachusetts5Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Tia T Raymond
- Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, Texas
| | - Robert A Berg
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial. Trials 2015; 16:245. [PMID: 26033094 PMCID: PMC4458338 DOI: 10.1186/s13063-015-0712-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 04/08/2015] [Indexed: 11/15/2022] Open
Abstract
Background The prevention of near and actual cardiopulmonary arrest in hospitalized children is a patient safety imperative. Prevention is contingent upon the timely identification, referral and treatment of children who are deteriorating clinically. We designed and validated a documentation-based system of care to permit identification and referral as well as facilitate provision of timely treatment. We called it the Bedside Paediatric Early Warning System (BedsidePEWS). Here we describe the rationale for the design, intervention and outcomes of the study entitled Evaluating Processes and Outcomes of Children in Hospital (EPOCH). Methods/Design EPOCH is a cluster-randomized trial of the BedsidePEWS. The unit of randomization is the participating hospital. Eligible hospitals have a Pediatric Intensive Care Unit (PICU), are anticipated to have organizational stability throughout the study, are not using a severity of illness score in hospital wards and are willing to be randomized. Patients are >37 weeks gestational age and <18 years and are hospitalized in inpatient ward areas during all or part of their hospital admission. Randomization is to either BedsidePEWS or control (no severity of illness score) in a 1:1 ratio within two strata (<200, ≥200 hospital beds). All-cause hospital mortality is the selected primary outcome. It is objective, independent of do-not-resuscitate status and can be reliably measured. The secondary outcomes include (1) clinical outcomes: clinical deterioration, severity of illness at and during ICU admission, and potentially preventable cardiac arrest; (2) processes of care outcomes: immediate calls for assistance, hospital and ICU readmission, and perceptions of healthcare professionals; and (3) resource utilization: ICU days and use of ICU therapies. Discussion Following funding by the Canadian Institutes of Health Research and local ethical approvals, site enrollment started in 2010 and was closed in February 2014. Patient enrollment is anticipated to be complete in July 2015. The results of EPOCH will strengthen the scientific basis for local, regional, provincial and national decision-making and for the recommendations of national and international bodies. If negative, the costs of hospital-wide implementation can be avoided. If positive, EPOCH will have provided a scientific justification for the major system-level changes required for implementation. Trial registration: NCT01260831 ClinicalTrials.gov date: 14 December 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0712-3) contains supplementary material, which is available to authorized users.
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What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study. Intensive Crit Care Nurs 2015; 31:91-9. [DOI: 10.1016/j.iccn.2014.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
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O'Leary F, Allwood M, McGarvey K, Howse J, Fahy K. Standardising paediatric resuscitation training in New South Wales, Australia: RESUS4KIDS. J Paediatr Child Health 2014; 50:405-10. [PMID: 24372678 DOI: 10.1111/jpc.12487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 11/27/2022]
Abstract
AIM A key competency for all health-care workers (HCWs) who care for children is the ability to respond to a child in respiratory or cardiorespiratory arrest. However, evidence suggests that medical and nursing staff may not have the knowledge and clinical skills to respond to these emergencies. The aim of this project was to create a standardised, evidence-based, paediatric life support course that would be available free to all HCWs in New South Wales (NSW), including NSW Ambulance. METHODS A paediatric life support course was designed along current education principles. It used e-learning as pre-learning and a face-to-face short practical course, combining team work and communication with practical paediatric resuscitation skills training. The programme was designed to empower local trainers to deliver a standardised course to local participants. RESULTS A total of 14,000 participants have completed the mandatory e-learning component, and over 8600 participants have completed the short practical course, across all NSW Local Health Districts, including NSW Ambulance. RESUS4KIDS has also been adopted by the universities of Sydney and Newcastle undergraduate medical and nursing programmes. Outside of NSW and ACT, over 400 participants have completed the course in facilities in Queensland, South Australia, Victoria and the Northern Territory. CONCLUSION We have developed a course that is available, at no cost to individuals or facilities, to all HCWs in NSW, including students, paramedics and general practitioners. We would encourage all other jurisdictions to consider adopting the programme.
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Affiliation(s)
- Fenton O'Leary
- RESUS4KIDS, NSW Child Health Networks, New South Wales, Australia; Sydney Medical School, University of Sydney, New South Wales, Australia; Emergency Department, The Children's Hospital at Westmead, New South Wales, Australia
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Tume LN, Sefton G, Arrowsmith P. Teaching paediatric ward teams to recognise and manage the deteriorating child. Nurs Crit Care 2013; 19:196-203. [PMID: 24147837 DOI: 10.1111/nicc.12050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 07/02/2013] [Accepted: 08/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Issues around the deterioration of hospitalised children are known: the failure to observe and monitor patients adequately, a failure to recognise the deteriorating patient, a failure to communicative effectively within the healthcare team and a failure to respond appropriately or in a timely manner (Pearson, 2008; NPSA, 2009). In response to this, a new 1-day course called RESPOND (Recognising Signs of Paediatric hOspital iNpatients Deterioration) was developed. OBJECTIVES To describe the development of the RESPOND course and present a preliminary evaluation of the first four courses. METHODS A written postcourse survey was completed by participants (junior doctors, medical students, nurses and health care assistants) immediately after the course and an electronic survey completed three months later in a large children's hospital in the North West of England. Data were analysed descriptively and by simple thematic analysis of free text responses. RESULTS Sixty-five participants undertook the RESPOND course over four separate days. Overwhelmingly participants found the course positive, with the most frequently cited benefit being improved multidisciplinary communication. Despite a poor response to the second survey, 18% (12 of 65) of respondents remained positive about the impact of the course. CONCLUSIONS AND RELEVANCE TO PRACTICE This preliminary evaluation combined with a reduction in hospital cardiac arrest rates suggest that the multiprofessional RESPOND course (in conjunction with an early warning tool and response system) is successful as part of a targeted strategy to promote patient safety within a children's hospital.
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Affiliation(s)
- Lyvonne N Tume
- L N Tume, RN RSCN RNT Dip App Sci (Nurs), B Nurs, M Clin Nurs (Crit Care), PGDE, PhD, Senior Nursing Research Fellow PICU, Alder Hey Children's NHS Foundation Trust and University of Central Lancashire, Liverpool, UK
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McLellan MC, Gauvreau K, Connor JA. Validation of the Cardiac Children's Hospital Early Warning Score: An Early Warning Scoring Tool to Prevent Cardiopulmonary Arrests in Children with Heart Disease. CONGENIT HEART DIS 2013; 9:194-202. [DOI: 10.1111/chd.12132] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Mary C. McLellan
- Cardiovascular Program Inpatient Unit; Boston Children's Hospital; Boston Mass USA
| | | | - Jean A. Connor
- Cardiovascular and Critical Care Services; Boston Children's Hospital; Boston Mass USA
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McLellan MC, Connor JA. The Cardiac Children's Hospital Early Warning Score (C-CHEWS). J Pediatr Nurs 2013; 28:171-8. [PMID: 22903065 DOI: 10.1016/j.pedn.2012.07.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 05/17/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
Inpatient pediatric cardiovascular patients have higher rates of cardiopulmonary arrests than other hospitalized children. Pediatric early warning scoring tools have helped to provide early identification and treatment to hospitalized children experiencing deterioration thus preventing arrests from occurring. However, the tools have rarely been used and have not been validated in the pediatric cardiac population. This paper describes the modification of a pediatric early warning scoring system for cardiovascular patients, the implementation of the tool, and its companion escalation of care algorithm on an inpatient pediatric cardiovascular unit.
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Affiliation(s)
- Mary C McLellan
- Cardiovascular Program Inpatient Unit, Boston Children's Hospital, Boston, MA, USA.
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Pitfield AF, Jamal S, Kissoon N. Updates in Pediatric Resuscitation: Recent Advances and Current Concepts. CURRENT PEDIATRICS REPORTS 2013. [DOI: 10.1007/s40124-012-0002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cardiopulmonary resuscitation in hospitalized children with cardiovascular disease: estimated prevalence and outcomes from the kids' inpatient database. Pediatr Crit Care Med 2013; 14:248-55. [PMID: 23462352 DOI: 10.1097/pcc.0b013e3182713329] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hospitalized children with cardiovascular disease may be at increased risk of cardiac arrest; however, little data exist regarding prevalence, risk factors, or outcomes of cardiopulmonary resuscitation in these patients. We sought to characterize national estimates of cardiopulmonary resuscitation and death after cardiopulmonary resuscitation for hospitalized children with cardiovascular disease. SETTING A total of 3,739 hospitals in 38 states participating in Kids' Inpatient Database. DESIGN Retrospective analysis of the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database was performed. Sample weighting was employed to produce national estimates. MEASUREMENTS AND MAIN RESULTS Cardiovascular disease was identified in 2.2% of the estimated 22,175,468 (95% confidence interval 21,391,343-22,959,592) hospitalizations. Cardiopulmonary resuscitation occurred in 0.74% (3,698; 95% confidence interval 3,205-4,191) of hospitalizations of children with cardiovascular disease, compared with 0.05% (11,726; 95% confidence interval 10,647-12,805) without cardiovascular disease (odds ratio 13.8, 95% confidence interval 12.8-15.0). The highest frequency of cardiopulmonary resuscitation occurred with myocarditis (3.0% of admissions), heart failure (2.0%), and coronary pathology (2.0%). Compared with other forms of cardiovascular disease identified in this study, single-ventricle patients were the only subgroup who exhibited a higher mortality after cardiopulmonary resuscitation (mortality 65% vs. 55%; odds ratio 1.7 [95% confidence interval 1.2-2.6]), while those who had undergone cardiac surgery exhibited a lower mortality rate (mortality 48% vs. 57%; odds ratio 0.6 [95% confidence interval 0.5-0.8]). CONCLUSIONS Cardiopulmonary resuscitation occurs in approximately 7 per 1,000 hospitalizations of children with cardiovascular disease, a rate greater than ten-fold that observed in hospitalizations of children without cardiovascular disease. Single-ventricle patients demonstrated increased mortality after cardiopulmonary resuscitation, while recent cardiac surgery was associated with a reduced odds of death after cardiopulmonary resuscitation. Further studies are needed to confirm these findings and develop techniques to prevent cardiac arrest in this high-risk population.
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Del Castillo J, López-Herce J, Matamoros M, Cañadas S, Rodriguez-Calvo A, Cechetti C, Rodriguez-Núñez A, Alvarez AC. Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children. Resuscitation 2012; 83:1456-61. [PMID: 22841610 DOI: 10.1016/j.resuscitation.2012.07.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 06/24/2012] [Accepted: 07/18/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Arterial hyperoxia after resuscitation has been associated with increased mortality in adults. The aim of this study was to test the hypothesis that post-resuscitation hyperoxia and hypocapnia are associated with increased mortality after resuscitation in pediatric patients. METHODS We performed a prospective observational multicenter hospital-based study including 223 children aged between 1 month and 18 years who achieved return of spontaneous circulation after in-hospital cardiac arrest and for whom arterial blood gas analysis data were available. RESULTS After return of spontaneous circulation, 8.5% of patients had hyperoxia (defined as PaO(2)>300 mm Hg) and 26.5% hypoxia (defined as PaO(2)<60 mm Hg). No statistical differences in mortality were observed when patients with hyperoxia (52.6%), hypoxia (42.4%), or normoxia (40.7%) (p=0.61). Hypocapnia (defined as PaCO(2)<30 mm Hg) was observed in 13.5% of patients and hypercapnia (defined as PaCO(2)>50 mm Hg) in 27.6%. Patients with hypercapnia or hypocapnia had significantly higher mortality (59.0% and 50.0%, respectively) than patients with normocapnia (33.1%) (p=0.002). At 24h after return of spontaneous circulation, neither PaO(2) nor PaCO(2) values were associated with mortality. Multiple logistic regression analysis showed that hypercapnia (OR, 3.27; 95% CI, 1.62-6.61; p=0.001) and hypocapnia (OR, 2.71; 95% CI, 1.04-7.05; p=0.04) after return of spontaneous circulation were significant mortality factors. CONCLUSIONS In children resuscitated from cardiac arrest, hyperoxemia after return of spontaneous circulation or 24h later was not associated with mortality. On the other hand, hypercapnia and hypocapnia were associated with higher mortality than normocapnia.
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Affiliation(s)
- Jimena Del Castillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Haque A, Rizvi A, Bano S. Outcome of in-hospital pediatric cardiopulmonary arrest from a single center in Pakistan. Indian J Pediatr 2011; 78:1356-60. [PMID: 21625844 DOI: 10.1007/s12098-011-0439-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 04/27/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the incidence and outcome of in-hospital pediatric cardiopulmonary arrest (CPA). METHODS This retrospective six-year case series was carried out at the PICU and Pediatric Units of Aga Khan University Hospital (AKUH). All children aged 1 month to 14 years who underwent cardiopulmonary resuscitation from January 2001 through December 2006 were included. Data were recorded according to the Utstein style. The outcome variables were sustained return of spontaneous circulation (initial survival) and hospital discharge (final survival). Factors associated with survival were evaluated using logistic regression analysis. RESULTS The incidence of CPA was 0.4% of all the admissions. Most of the CPR attempts took place in pediatric intensive care unit (53%) and the most frequent etiology was shock (78%). After initial CPR, the sustained return of spontaneous circulation was achieved in 58 patients (55%). Only 12 patients (11%) were discharged alive from the hospital. The most common initial documented rhythm was bradycardia (78%). Multivariate logistic regression analysis revealed that prolonged duration of CPR (>20 min) was the best predictor of initial and final mortality (p < 0.001). CONCLUSIONS The survival rate of in-hospital pediatric cardiopulmonary arrest in the present report is low.
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Affiliation(s)
- Anwarul Haque
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan.
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Kennedy CE, Turley JP. Time series analysis as input for clinical predictive modeling: modeling cardiac arrest in a pediatric ICU. Theor Biol Med Model 2011; 8:40. [PMID: 22023778 PMCID: PMC3213024 DOI: 10.1186/1742-4682-8-40] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 10/24/2011] [Indexed: 11/10/2022] Open
Abstract
Background Thousands of children experience cardiac arrest events every year in pediatric intensive care units. Most of these children die. Cardiac arrest prediction tools are used as part of medical emergency team evaluations to identify patients in standard hospital beds that are at high risk for cardiac arrest. There are no models to predict cardiac arrest in pediatric intensive care units though, where the risk of an arrest is 10 times higher than for standard hospital beds. Current tools are based on a multivariable approach that does not characterize deterioration, which often precedes cardiac arrests. Characterizing deterioration requires a time series approach. The purpose of this study is to propose a method that will allow for time series data to be used in clinical prediction models. Successful implementation of these methods has the potential to bring arrest prediction to the pediatric intensive care environment, possibly allowing for interventions that can save lives and prevent disabilities. Methods We reviewed prediction models from nonclinical domains that employ time series data, and identified the steps that are necessary for building predictive models using time series clinical data. We illustrate the method by applying it to the specific case of building a predictive model for cardiac arrest in a pediatric intensive care unit. Results Time course analysis studies from genomic analysis provided a modeling template that was compatible with the steps required to develop a model from clinical time series data. The steps include: 1) selecting candidate variables; 2) specifying measurement parameters; 3) defining data format; 4) defining time window duration and resolution; 5) calculating latent variables for candidate variables not directly measured; 6) calculating time series features as latent variables; 7) creating data subsets to measure model performance effects attributable to various classes of candidate variables; 8) reducing the number of candidate features; 9) training models for various data subsets; and 10) measuring model performance characteristics in unseen data to estimate their external validity. Conclusions We have proposed a ten step process that results in data sets that contain time series features and are suitable for predictive modeling by a number of methods. We illustrated the process through an example of cardiac arrest prediction in a pediatric intensive care setting.
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Affiliation(s)
- Curtis E Kennedy
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, WT 6-006, Houston, TX 77030, USA.
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Berens RJ, Cassidy LD, Matchey J, Campbell D, Colpaert KD, Welch T, Lawson M, Peterson C, O'Flynn J, Dearth M, Tieves KS. Probability of survival based on etiology of cardiopulmonary arrest in pediatric patients. Paediatr Anaesth 2011; 21:834-40. [PMID: 21199129 DOI: 10.1111/j.1460-9592.2010.03479.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To aggregate data across institutions to identify, characterize, and differentiate potential survivors from nonsurvivors based on etiology of event. AIM To evaluate the association of the cardiopulmonary resuscitation (CPR) duration and probability of survival (Ps), stratified by etiology of arrest. BACKGROUND In-hospital cardiac arrests occur in 2-6% of pediatric patients with poor survival rates resulting in significant expenditures of time and resources. METHODS Retrospective data from six pediatric hospitals on patients suffering from pulseless cardiac arrests receiving CPR for over one minute were analyzed. Data included demographics, reason for code, precardiac arrest diagnosis, devices and treatment, management strategies during cardiac arrest, compression duration, outcome at hospital discharge, and neurologic outcome of survivors at hospital discharge. Results of logistic regression analysis generated predicated probabilities of survival for duration of compression. Patients were stratified by cardiac-induced cardiac arrests (CICA) and respiratory-induced cardiac arrest (RICA). RESULTS A total of 257 patients were included, and 27% of CICA and 35% of RICA patients survived to hospital discharge. Ps was initially lower for the CICA patients (Ps at 1 min = 29%) and remained constant (Ps at 60 min = 25%). RICA patients'Ps was higher initially (Ps at 1 min = 62%) but demonstrated a dramatic drop within the first 60 min of CPR (Ps at 60 min = 0.2%). CONCLUSIONS Probability of survival curves based on duration of CPR was statistically significantly different for CICA patients compared to RICA patients.
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Tress EE, Kochanek PM, Saladino RA, Manole MD. Cardiac arrest in children. J Emerg Trauma Shock 2011; 3:267-72. [PMID: 20930971 PMCID: PMC2938492 DOI: 10.4103/0974-2700.66528] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 04/24/2010] [Indexed: 01/15/2023] Open
Abstract
Major advances in the field of pediatric cardiac arrest (CA) were made during the last decade, starting with the publication of pediatric Utstein guidelines, the 2005 recommendations by the International Liaison Committee on Resuscitation, and culminating in multicenter collaborations. The epidemiology and pathophysiology of in-hospital and out-of-hospital CA are now well described. Four phases of CA are described and the term “post-cardiac arrest syndrome” has been proposed, along with treatment goals for each of its four phases: immediate post-arrest, early post-arrest, intermediate and recovery phase. Hypothermia is recommended to be considered as a therapy for post-CA syndrome in comatose patients after CA, and large multicenter prospective studies are underway. We reviewed landmark articles related to pediatric CA published during the last decade. We present the current knowledge of epidemiology, pathophysiology and treatment of CA relevant to pre-hospital and acute care health practitioners.
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Affiliation(s)
- Erika E Tress
- University of Pittsburgh School of Medicine, Departments of Pediatrics and Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA, 152 60, USA
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Wang GS, Erwin N, Zuk J, Henry DB, Dobyns EL. Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital. J Hosp Med 2011; 6:131-5. [PMID: 21387548 DOI: 10.1002/jhm.832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 03/03/2010] [Accepted: 07/02/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Pediatric in-hospital arrests are uncommon but are associated with poor outcomes. In preparation for implenting a Rapid Response Team (RRT) at The Children's Hospital, we reviewed our data collection of 13 years of emergency response team (ERT) activations. We describe demographic and clinical variables, including outcomes of ERT activations at a free-standing tertiary care children's hospital. METHODS Analysis was performed on data collected from January 1993 through July 2007. Variables collected included age, sex, admission diagnosis, core event, admission diagnosis and secondary diagnosis, medical division or winter/nonwinter months, day/night shifts, survival of core event, survival to discharge, and primary attending service. RESULTS There were 1537 ERT activations in the database, 203 were eliminated due to missing data or were adult visitors/employees. The remaining 1334 were included for analysis. Our results showed 39%(511) of all ERT activations occurred in patients under 1 year of age. The most common admission diagnosis category was cardiac disease. There was no statistical significance between summer and winter months although more activations occurred during daytime hours (P < .001). Survival rate of an ERT was 90%, with a 78% survival rate to discharge. CONCLUSION Our data support the general belief that younger children with chronic disease are at highest risk for ERT activations. These risk factors should be taken into consideration when planning patient placement, medical staffing, and the threshold for ICU consultations or admissions. More extensive multisite studies using clinical data are necessary to further identify hospitalized children at risk for sudden decompensation.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine, The Children's Hospital, Aurora, Colorado, USA.
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Garden AL, Mills SA, Wilson R, Watts P, Griffin JM, Gannon S, Kapoor I. In Situ Simulation Training for Paediatric Cardiorespiratory Arrest: Initial Observations and Identification of Latent Errors. Anaesth Intensive Care 2010; 38:1038-42. [DOI: 10.1177/0310057x1003800613] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.
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Affiliation(s)
- A. L. Garden
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Associate Professor and Clinical Associate Director
| | - S. A. Mills
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Paediatric Fellow, Department of Child Health, Wellington Regional Hospital
| | - R. Wilson
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Specialist Paediatrician and Clinical Leader, Department of Child Health, Wellington Regional Hospital
| | - P. Watts
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Technology Specialist, National Patient Simulation Training Centre, Wellington Regional Hospital
| | - J. M. Griffin
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Clinical Nurse Specialist, Department of Child Health, Wellington Regional Hospital
| | - S. Gannon
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Clinical Nurse Educator, Department of Child Health, Wellington Regional Hospital
| | - I. Kapoor
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Specialist Anaesthetist, Department of Anaesthesia, Wellington Hospital
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Anwar-ul-Haque, Saleem AF, Zaidi S, Haider SR. Experience of pediatric rapid response team in a tertiary care hospital in Pakistan. Indian J Pediatr 2010; 77:273-6. [PMID: 20177830 DOI: 10.1007/s12098-010-0032-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 12/02/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report our experience before and after implementation of pediatric rapid response team (RRT) in pediatric wards of a tertiary care hospital in Pakistan. METHODS An audit of RRT activity from December 2007 to August 2008 was conducted and reviewed patient diagnoses at the time of call placement, interventions done and post-intervention clinical outcomes. Clinical Outcomes in the nine months before RRT implementation were compared with those in the first operational nine months after RRT. RESULTS Eighty-three calls were generated during the post-intervention study period of 9-month (21 calls/1000 admissions). The median age of patients was 27 months; 37% calls were for infants. The majority of patients were under care of medical services (93% vs 7% under care of surgical services). Greater numbers of calls were made during 0800-1600 hours (45%). Respiratory issues were the most common reason for activation of RRT. Because of early interventions, majority (61%) of patients avoided unnecessary PICU stay and expenditure; only 17% required mechanical ventilation in PICU. The code rate per 1000 admissions decreased from 5.2 (pre-RRT) to 2.7 (post-RRT) (p=0.08; OR 1.88 (95%Cl 0.9-3.93). The mortality rate of patients admitted in PICU from wards decreased from 50% to 15% (p=0.25; OR 1.64 (95%Cl 0.63-4.29). CONCLUSION Our experience with implementation of RRT was associated with reduction in cardiorespiratory arrest, mortality and saved a lot of PICU resource utilization. It is an excellent patient-safety initiative especially in resource-constrained countries by bringing PICU reflexes outside the PICU.
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Affiliation(s)
- Anwar-ul-Haque
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan.
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Chapman SM, Grocott MPW, Franck LS. Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration. Intensive Care Med 2009; 36:600-11. [DOI: 10.1007/s00134-009-1715-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 08/13/2009] [Indexed: 11/29/2022]
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Family Alert: Implementing Direct Family Activation of a Pediatric Rapid Response Team. Jt Comm J Qual Patient Saf 2009; 35:575-80. [DOI: 10.1016/s1553-7250(09)35078-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Life-threatening events are common in today's hospitals, where an increasing proportion of patients with urgent admission are cared for by understaffed, often inexperienced personnel. Medical errors play a key role in causing adverse events and failure to rescue deteriorating patients. In-hospital cardiac arrest outcomes are generally poor, but these events are often preceded by a pattern of deterioration with abnormal vital signs and mental status. When hospital staff or family members observe warning signs and trigger timely intervention by a rapid response team, rates of cardiac arrest and mortality can be reduced. Rapid response team involvement can be used to trigger careful review of preceding events to help uncover important systems issues and allow for further improvements in patient safety.
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Extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: lessons from acute neurotoxicity. Pediatr Crit Care Med 2009; 10:525-7. [PMID: 19584639 DOI: 10.1097/pcc.0b013e3181a0dfb0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pediatric Evidence-Based Practice. AACN Adv Crit Care 2009; 20:19-25. [DOI: 10.1097/nci.0b013e31819436ba] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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