American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest

Effect of dimethyl fumarate on mitochondrial metabolism in a pediatric porcine model of asphyxia-induced in-hospital cardiac arrest

Neurological and cardiac injuries are significant contributors to morbidity and mortality following pediatric in-hospital cardiac arrest (IHCA). Preservation of mitochondrial function may be critical for reducing these injuries. Dimethyl fumarate (DMF) has shown potential to enhance mitochondrial content and reduce oxidative damage. To investigate the efficacy of DMF in mitigating mitochondrial injury in a pediatric porcine model of IHCA, toddler-aged piglets were subjected to asphyxia-induced CA, followed by ventricular fibrillation, high-quality cardiopulmonary resuscitation, and random assignment to receive either DMF (30 mg/kg) or placebo for four days. Sham animals underwent similar anesthesia protocols without CA. After four days, tissues were analyzed for mitochondrial markers. In the brain, untreated CA animals exhibited a reduced expression of proteins of the oxidative phosphorylation system (CI, CIV, CV) and decreased mitochondrial respiration (p < 0.001). Despite alterations in mitochondrial content and morphology in the myocardium, as assessed per transmission electron microscopy, mitochondrial function was unchanged. DMF treatment counteracted 25% of the proteomic changes induced by CA in the brain, and preserved mitochondrial structure in the myocardium. DMF demonstrates a potential therapeutic benefit in preserving mitochondrial integrity following asphyxia-induced IHCA. Further investigation is warranted to fully elucidate DMF's protective mechanisms and optimize its therapeutic application in post-arrest care.

A proof-of-concept study evaluating cardiac compression techniques for cardiopulmonary resuscitation in laying hens (Gallus gallus)

OBJECTIVE

To determine in adult chickens which of 3 CPR techniques, sternal compressions (SC), SC with interposed caudal coelomic compressions (ICCC), or lateral compressions (LC), results in the highest mean systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) as measured directly from the carotid artery.

DESIGN

Prospective, nonblinded, experimental crossover study.

SETTING

University teaching hospital laboratory.

ANIMALS

Ten retired laying hens.

INTERVENTIONS

Birds were sedated, anesthetized, and placed in dorsal recumbency. A carotid artery catheter was placed to directly measure arterial pressure. Ventricular fibrillation was induced with direct cardiac stimulation using a 9-Volt battery. Each bird then received 2 minutes of the 3 different cardiac compression techniques in a random order by 3 different compressors, with the compressor order also randomized. Birds were subsequently administered IV epinephrine, and transthoracic defibrillation was attempted. At the end of experimentation, each bird was euthanized, and simple gross necropsies were performed. Linear mixed models followed by pairwise paired t-tests were performed to evaluate differences in pressures generated by each technique.

MEASUREMENTS AND MAIN RESULTS

The primary study outcomes were SAP, DAP, and MAP over 2 minutes of compressions for each compression technique. Pressures from ICCC (SAP: 27.6 ± 5.3 mm Hg, DAP: 18.7 ± 5.2 mm Hg, MAP: 21.7 ± 5.2 mm Hg) were significantly higher than those from LC (SAP: 18.9 ± 5.4 mm Hg, DAP: 11.6 ± 4.1 mm Hg, MAP: 14.1 ± 4.5 mm Hg). Pressures from SC (SAP: 24.5 ± 6.4 mm Hg, DAP: 15.2 ± 4.3 mm Hg, MAP: 18.3 ± 5.0 mm Hg) were not significantly different from ICCC or LC.

CONCLUSIONS

External compressions can generate detectable increases in arterial pressure in chickens with ventricular fibrillation. SC with ICCC generated significantly higher arterial pressures than LC. SC alone generated blood pressures that were not significantly different from those generated by SC with ICCC or LC.

Measuring the Quality of Cardiopulmonary Resuscitation in the Emergency Department at a Quaternary Children's Hospital

AIM OF STUDY

The aim of this study was to evaluate the quality of cardiopulmonary resuscitation (CPR) as it relates to American Heart Association (AHA) guidelines during cardiac arrests in a pediatric emergency department at a quaternary children's hospital.

BACKGROUND AND OBJECTIVES

High-quality CPR increases the likelihood of survival from pediatric out-of-hospital cardiac arrest. However, optimal performance of high-quality CPR during transition of care between prehospital and pediatric emergency department providers is challenging, and survival without comorbidities remains extremely low for out-of-hospital cardiac arrest.

METHODS

This was a retrospective study of data collected from a free-standing children's hospital emergency department and level 1 trauma center.

RESULTS

There were 23 pediatric CPR events for subjects younger than 18 years in the emergency department during the time of the study. Median chest compression (CC) fraction was 85% overall with the AHA goal of 80%. Compliance with this recommendation was achieved in all age groups. The CC rate averaged 112 for the entire sample. Median depth was 2.06 cm in subjects younger than 1 year, 3.95 cm in subjects 1 year old to younger than 8 years, and 5.33 cm in subjects 8 years old to younger than 18 years. These compression depth rates fell below the AHA recommendations, with the exception of those 8 years and older.

CONCLUSIONS

In our study, CC fraction and CC rate were found to meet AHA targets for all age groups, whereas CC depth only met AHA targets for the 8- to 18-year-old group. The most difficult parameter was CC depth for the group of subjects younger than 1 year.

A randomized and blinded trial of inhaled nitric oxide in a piglet model of pediatric cardiopulmonary resuscitation

AIM

Inhaled nitric oxide (iNO) during cardiopulmonary resuscitation (CPR) improved systemic hemodynamics and outcomes in a preclinical model of adult in-hospital cardiac arrest (IHCA) and may also have a neuroprotective role following cardiac arrest. The primary objectives of this study were to determine if iNO during CPR would improve cerebral hemodynamics and mitochondrial function in a pediatric model of lipopolysaccharide-induced shock-associated IHCA.

METHODS

After lipopolysaccharide infusion and ventricular fibrillation induction, 20 1-month-old piglets received hemodynamic-directed CPR and were randomized to blinded treatment with or without iNO (80 ppm) during and after CPR. Defibrillation attempts began at 10 min with a 20-min maximum CPR duration. Cerebral tissue from animals surviving 1-h post-arrest underwent high-resolution respirometry to evaluate the mitochondrial electron transport system and immunohistochemical analyses to assess neuropathology.

RESULTS

During CPR, the iNO group had higher mean aortic pressure (41.6 ± 2.0 vs. 36.0 ± 1.4 mmHg; p = 0.005); diastolic BP (32.4 ± 2.4 vs. 27.1 ± 1.7 mmHg; p = 0.03); cerebral perfusion pressure (25.0 ± 2.6 vs. 19.1 ± 1.8 mmHg; p = 0.02); and cerebral blood flow relative to baseline (rCBF: 243.2 ± 54.1 vs. 115.5 ± 37.2%; p = 0.02). Among the 8/10 survivors in each group, the iNO group had higher mitochondrial Complex I oxidative phosphorylation in the cerebral cortex (3.60 [3.56, 3.99] vs. 3.23 [2.44, 3.46] pmol O₂/s mg; p = 0.01) and hippocampus (4.79 [4.35, 5.18] vs. 3.17 [2.75, 4.58] pmol O₂/s mg; p = 0.02). There were no other differences in mitochondrial respiration or brain injury between groups.

CONCLUSIONS

Treatment with iNO during CPR resulted in superior systemic hemodynamics, rCBF, and cerebral mitochondrial Complex I respiration in this pediatric cardiac arrest model.

Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review

IMPORTANCE

Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR).

OBSERVATIONS

Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes.

CONCLUSIONS AND RELEVANCE

Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.

Impact of Infant Positioning on Cardiopulmonary Resuscitation Performance During Simulated Pediatric Cardiac Arrest: A Randomized Crossover Study

OBJECTIVES

The primary objective was to determine the impact of infant positioning on cardiopulmonary resuscitation performance during simulated pediatric cardiac arrest.

DESIGN

A single-center, prospective, randomized, unblinded manikin study.

SETTING

Medical university-affiliated simulation facility.

SUBJECTS

Fifty-two first-line professional rescuers (n = 52).

INTERVENTIONS

Performance of cardiopulmonary resuscitation was determined using an infant manikin model in three different positions (on a table [T], on the provider's forearm with the manikin's head close to the provider's elbow [P], and on the provider's forearm with the manikin's head close to the provider's palm [D]). For the measurement of important cardiopulmonary resuscitation performance variables, a commercially available infant simulator was modified. In a randomized sequence, healthcare professionals performed single-rescuer cardiopulmonary resuscitation for 3 minutes in each position. Performances of chest compression (primary outcome), ventilation, and hands-off time were analyzed using a multilevel regression model.

MEASUREMENTS AND MAIN RESULTS

Mean (± SD) compression depth significantly differed between table and the other two manikin positions (31 ± 2 [T], 29 ± 3 [P], and 29 ± 3 mm [D]; overall p < 0.001; repeated measures design adjusted difference: T vs P, -2 mm [95% CI, -2 to -1 mm]; T vs D, -1 mm [95% CI, -2 to -1 mm]). Secondary outcome variables showed no significant differences.

CONCLUSIONS

Compressions were significantly deeper in the table group compared to positions on the forearm during cardiopulmonary resuscitation, yet the differences were small and perhaps not clinically important.

Epidemiology of pediatric cardiopulmonary resuscitation

OBJECTIVE

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

SOURCE OF DATA

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

SYNTHESIS OF DATA

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

CONCLUSIONS

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

Factors affecting the course of resuscitation from cardiac arrest with pulseless electrical activity in children and adolescents

BACKGROUND

Although in-hospital pediatric cardiac arrests and cardiopulmonary resuscitation occur >15,000/year in the US, few studies have assessed which factors affect the course of resuscitation in these patients. We investigated transitions from Pulseless Electrical Activity (PEA) to Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT), Return of Spontaneous Circulation (ROSC) and recurrences from ROSC to PEA in children and adolescents with in-hospital cardiac arrest.

METHODS

Episodes of cardiac arrest at the Children's Hospital of Philadelphia were prospectively registered. Defibrillators that recorded chest compression depth/rate and ventilation rate were applied. CPR variables, patient characteristics and etiology, and dynamic factors (e.g. the proportion of time spent in PEA or ROSC) were entered as time-varying covariates for the transition intensities under study.

RESULTS

In 67 episodes of CPR in 59 patients (median age 15 years) with cardiac arrest, there were 52 transitions from PEA to ROSC, 22 transitions from PEA to VF/pVT, and 23 recurrences of PEA from ROSC. Except for a nearly significant effect of mean compression depth beyond a threshold of 5.7 cm, only dynamic factors that evolved during CPR favored a transition from PEA to ROSC. The latter included a lower proportion of PEA over the last 5 min and a higher proportion of ROSC over the last 5 min. Factors associated with PEA to VF/pVT development were age, weight, the proportion spent in VF/pVT or PEA the last 5 min, and the general transition intensity, while PEA recurrence from ROSC only depended on the general transition intensity.

CONCLUSION

The clinical course during pediatric cardiac arrest was mainly influenced by dynamic factors associated with time in PEA and ROSC. Transitions from PEA to ROSC seemed to be favored by deeper compressions.

Pediatric cardiopulmonary resuscitation quality during intra-hospital transport

AIM

To evaluate pediatric cardiopulmonary resuscitation (CPR) quality during intra-hospital transport to facilitate extracorporeal membrane oxygenation (ECMO)-CPR (ECPR). We compared chest compression (CC) rate, depth, and fraction (CCF) between the pre-transport and intra-transport periods.

METHODS

Observational study of children <18 years with either in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) who underwent transport between two care locations within the hospital for ECPR and who had CPR mechanics data available. Descriptive patient and arrest characteristics were summarized. The primary analysis compared pre- to intra-transport CC rate, depth, and fraction. A secondary analysis compared the proportion of pre- versus intra-transport 60-s epochs meeting guideline recommendations for rate (100-120/min), depth (≥4 cm for infants; ≥5 cm for children ≥1 year), and CCF (≥0.80).

RESULTS

Seven patients (four IHCA; three witnessed OHCA) met eligibility criteria. Six (86%) patients survived the event and two (28%) survived to hospital discharge. Median transport CPR duration was 7 [IQR 5.5, 8.5] minutes. There were no differences in pre- vs. intra-transport CC rate (115 [113, 118] vs. 118 [114, 127] CCs/minute; p = 0.18), depth (3.2 [2.7, 4.4] vs. 3.6 [2.5, 4.6] cm; p = 0.50), or CCF (0.89 [0.82, 0.90] vs. 0.92 [0.79, 0.97]; p = 0.31). Equivalent proportions of 60-s CPR epochs met guideline recommendations between pre- and intra-transport (rate: 66% vs. 57% [p = 0.22]; depth: 14% vs. 19% [p = 0.39]; CCF: 80% vs. 75% [p = 0.43]).

CONCLUSIONS

Pediatric CPR quality was maintained during intra-hospital patient transport, suggesting that it is reasonable for ECPR systems to incorporate patient transport to facilitate ECMO cannulation.

Variability in chest compression rate calculations during pediatric cardiopulmonary resuscitation

AIM

The mathematical method used to calculate chest compression (CC) rate during cardiopulmonary resuscitation varies in the literature and across device manufacturers. The objective of this study was to determine the variability in calculated CC rates by applying four published methods to the same dataset.

METHODS

This study was a secondary investigation of the first 200 pediatric cardiac arrest events with invasive arterial line waveform data in the ICU-RESUScitation Project (NCT02837497). Instantaneous CC rates were calculated during periods of uninterrupted CCs. The defined minimum interruption length affects rate calculation (e.g., if an interruption is defined as a break in CCs ≥ 2 s, the lowest possible calculated rate is 30 CCs/min). Average rates were calculated by four methods: 1) rate with an interruption defined as ≥ 1 s; 2) interruption ≥ 2 s; 3) interruption ≥ 3 s; 4) method #3 excluding top and bottom quartiles of calculated rates. American Heart Association Guideline-compliant rate was defined as 100-120 CCs/min. A clinically important change was defined as ±5 CCs/min. The percentage of events and epochs (30 s periods) that changed Guideline-compliant status was calculated.

RESULTS

Across calculation methods, mean CC rates (118.7-119.5/min) were similar. Comparing all methods, 14 events (7%) and 114 epochs (6%) changed Guideline-compliant status.

CONCLUSION

Using four published methods for calculating CC rate, average rates were similar, but 7% of events changed Guideline-compliant status. These data suggest that a uniform calculation method (interruption ≥ 1 s) should be adopted to decrease variability in resuscitation science.

Survival and Cardiopulmonary Resuscitation Hemodynamics Following Cardiac Arrest in Children With Surgical Compared to Medical Heart Disease

OBJECTIVES

To assess the association of diastolic blood pressure cutoffs (≥ 25 mm Hg in infants and ≥ 30 mm Hg in children) during cardiopulmonary resuscitation with return of spontaneous circulation and survival in surgical cardiac versus medical cardiac patients. Secondarily, we assessed whether these diastolic blood pressure targets were feasible to achieve and associated with outcome in physiology unique to congenital heart disease (single ventricle infants, open chest), and influenced outcomes when extracorporeal cardiopulmonary resuscitation was deployed.

DESIGN

Multicenter, prospective, observational cohort analysis.

SETTING

Tertiary PICU and cardiac ICUs within the Collaborative Pediatric Critical Care Research Network.

PATIENTS

Patients with invasive arterial catheters during cardiopulmonary resuscitation and surgical cardiac or medical cardiac illness category.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic waveforms during cardiopulmonary resuscitation were analyzed on 113 patients, 88 surgical cardiac and 25 medical cardiac. A similar percent of surgical cardiac (51/88; 58%) and medical cardiac (17/25; 68%) patients reached the diastolic blood pressure targets (p = 0.488). Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients (p = 0.018), but not medical cardiac patients (p = 0.359). Fifty-three percent (16/30) of patients with single ventricles attained the target diastolic blood pressure. In patients with an open chest at the start of chest compressions, 11 of 20 (55%) attained the target diastolic blood pressure. In the 33 extracorporeal cardiopulmonary resuscitation patients, 16 patients (48%) met the diastolic blood pressure target with no difference between survivors and nonsurvivors (p = 0.296).

CONCLUSIONS

During resuscitation in an ICU, with invasive monitoring in place, diastolic blood pressure targets of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children can be achieved in patients with both surgical and medical heart disease. Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients, but not medical cardiac patients. Diastolic blood pressure targets were feasible to achieve in 1) single ventricle patients, 2) open chest physiology, and 3) extracorporeal cardiopulmonary resuscitation patients.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?

BACKGROUND

Treating patients in cardiac arrest (CA) with mechanical chest compressions (MCC) during percutaneous coronary intervention (PCI) is now routine in many coronary catheterization laboratories (cath-lab) and more aggressive treatment modalities, including extracorporeal CPR are becoming more common. The cath-lab setting enables monitoring of vital physiological parameters and other clinical factors that can potentially guide the resuscitation effort. This retrospective analysis attempts to identify such factors associated with ROSC and survival.

METHODS

In thirty-five patients of which background data, drugs used during the resuscitation and the intervention, PCI result, post ROSC-treatment and physiologic data collected during CPR were compared for prediction of ROSC and survival.

RESULTS

Eighteen (51%) patients obtained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between groups in regards of background data. Patients arriving in the cath-lab with ongoing resuscitation efforts had lower ROSC rate (22% vs 53%; p = 0.086) and no survivors (0% vs 50%, p = 0.001). CPR time also differentiated resuscitation outcomes (ROSC: 18 min vs No ROSC: 50 min; p = 0.007 and Survivors: 10 min vs No Survivors: 45 min; p = 0.001). Higher arterial diastolic blood pressure was associated with ROSC: 30 mmHg vs No ROSC: 19 mmHg; p = 0.012).

CONCLUSION

Aortic diastolic pressure during CPR is the most predictive physiological parameter of resuscitation success. Ongoing CPR upon arrival at the cath-lab and continued MCC beyond 10-20 min in the cath-lab were both predictive of poor outcomes. These factors can potentially guide decisions regarding escalation and termination of resuscitation efforts.

Physiology-directed cardiopulmonary resuscitation: advances in precision monitoring during cardiac arrest

PURPOSE OF REVIEW

We review the recent advances in physiologic monitoring during cardiac arrest and offer an evidence-based framework for prioritizing physiologic targets during cardiopulmonary resuscitation (CPR).

RECENT FINDINGS

Current CPR guidelines recommend a uniform approach for all patients in cardiac arrest, but newer data support a precision strategy that uses the individual patient's physiology to guide resuscitation. Coronary perfusion pressure and arterial DBP are associated with survival outcomes in recent animal and human studies. End-tidal carbon dioxide is a reasonable noninvasive alternative, but may be inferior to invasive hemodynamic endpoints. Cerebral oximetry and cardiac ultrasound are emerging physiologic indicators of CPR effectiveness.

SUMMARY

Physiologic monitoring can and should be used to deliver precision CPR whenever possible and may improve outcomes after cardiac arrest.

Hemodynamic effects of chest compression interruptions during pediatric in-hospital cardiopulmonary resuscitation

AIM

Animal studies have established deleterious hemodynamic effects of interrupting chest compressions. The objective of this study was to evaluate the effect of interruptions on invasively measured blood pressures (BPs) during pediatric in-hospital cardiac arrest (IHCA).

METHODS

This was a single-center, observational study of pediatric (<18 years) intensive care unit IHCAs in patients with invasive arterial catheters in place. Interruptions were defined as ≥1 s between chest compressions. Diastolic BP (DBP) and systolic BP (SBP) were determined for individual compressions. For the primary analysis, the average DBP and SBP of the 20 compressions preceding each interruption were compared to the average DBP and SBP of the first 20 compressions following each interruption utilizing non-parametric paired analyses. Linear regression evaluated the change in DBP during interruptions and following interruptions.

RESULTS

Thirty-two IHCA events met inclusion criteria, yielding 161 evaluable interruptions. The median age was 2.1 years. Return of circulation was achieved in 24 (75%). The median interruption duration was 2.4 [1.4, 7.0] seconds. Most patients were intubated pre-arrest and received epinephrine during CPR. BPs were not different pre- vs. post-interruption (DBP: 28.7 [21.6, 38.2] vs. 28.3 [21.0, 37.4] mmHg, p = 0.81; SBP: 82.0 [51.7, 116.7] vs. 85.4 [55.7, 122.2] mmHg, p = 0.07). DBP decreased 8.41 ± 0.73 mmHg (p < 0.001) during the first second of interruptions and 0.19 ± 0.02 mmHg/s (p < 0.001) in subsequent seconds.

CONCLUSIONS

BPs following chest compression interruptions did not differ from pre-interruption BPs. These findings suggest that in the setting of high-quality in-hospital CPR, brief chest compression interruptions do not have persistent detrimental hemodynamic impact.

Predicting cardiac arrests in pediatric intensive care units

BACKGROUND

Early identification of children at risk for cardiac arrest would allow for skill training associated with improved outcomes and provides a prevention opportunity.

OBJECTIVE

Develop and assess a predictive model for cardiopulmonary arrest using data available in the first 4 h.

METHODS

Data from PICU patients from 8 institutions included descriptive, severity of illness, cardiac arrest, and outcomes.

RESULTS

Of the 10074 patients, 120 satisfying inclusion criteria sustained a cardiac arrest and 67 (55.9%) died. In univariate analysis, patients with cardiac arrest prior to admission were over 6 times and those with cardiac arrests during the first 4 h were over 50 times more likely to have a subsequent arrest. The multivariate logistic regression model performance was excellent (area under the ROC curve = 0.85 and Hosmer-Lemeshow statistic, p = 0.35). The variables with the highest odds ratio's for sustaining a cardiac arrest in the multivariable model were admission from an inpatient unit (8.23 (CI: 4.35-15.54)), and cardiac arrest in the first 4 h (6.48 (CI: 2.07-20.36). The average risk predicted by the model was highest (11.6%) among children sustaining an arrest during hours >4-12 and continued to be high even for days after the risk assessment period; the average predicted risk was 9.5% for arrests that occurred after 8 PICU days.

CONCLUSIONS

Patients at high risk of cardiac arrest can be identified with routinely available data after 4 h. The cardiac arrest may occur relatively close to the risk assessment period or days later.

Comparison of Pediatric Cardiopulmonary Resuscitation Quality in Classic Cardiopulmonary Resuscitation and Extracorporeal Cardiopulmonary Resuscitation Events Using Video Review

OBJECTIVES

To assess differences in cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation events using video recordings of actual pediatric cardiac arrest events.

DESIGN

Single-center, prospective, observational trial.

SETTING

Tertiary-care pediatric teaching hospital, cardiac ICU.

PATIENTS

All patients admitted to the pediatric cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Seventeen events comprising 264.5 minutes of cardiopulmonary resuscitation were included: 11 classic cardiopulmonary resuscitation events (87.5 min) and six extracorporeal cardiopulmonary resuscitation events (177 min). Events were divided into 30-second epochs, and cardiopulmonary resuscitation quality markers were assessed using video and telemetry data review of goal endpoints: end-tidal carbon dioxide greater than or equal to 15 mm Hg, diastolic blood pressure greater than or equal to 30 mm Hg, chest compression fraction greater than 80% per epoch, and chest compression rate between 100 and 120 chest compression per minute. Additionally, each chest compression pause (hands-off event) was recorded and timed. When compared with extracorporeal cardiopulmonary resuscitation, classic cardiopulmonary resuscitation epochs were more likely to have end-tidal carbon dioxide greater than or equal to 15 mm Hg (56% vs 6.2%; p = 0.01) and provide chest compression between 100 and 120 times per minute (112 vs 134 chest compression per minute; p < 0.001). No difference was found between classic cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation in compliance with diastolic blood pressure greater than or equal to 30 mm Hg (38% classic cardiopulmonary resuscitation vs 30% extracorporeal cardiopulmonary resuscitation). There were 135 hands-off events: 52 in classic cardiopulmonary resuscitation and 83 in extracorporeal cardiopulmonary resuscitation (p = 0.12).

CONCLUSIONS

Classic cardiopulmonary resuscitation had superior adherence to end-tidal carbon dioxide goals and chest compression rate guidelines than extracorporeal cardiopulmonary resuscitation.

Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative

OBJECTIVES

Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals.

DESIGN

Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017.

SETTING

Twelve pediatric hospitals across United States, Canada, and Europe.

PATIENTS

In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3 cm (1.9-3.0 cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8 cm (2.9-4.6 cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5 cm (4.0-6.5 cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4 cm in less than 1 year, greater than or equal to 4.4 cm in 1 to less than 8 years, and 4.5 to less than 6.6 cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112).

CONCLUSIONS

Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival

BACKGROUND

On the basis of laboratory cardiopulmonary resuscitation (CPR) investigations and limited adult data demonstrating that survival depends on attaining adequate arterial diastolic blood pressure (DBP) during CPR, the American Heart Association recommends using blood pressure to guide pediatric CPR. However, evidence-based blood pressure targets during pediatric CPR remain an important knowledge gap for CPR guidelines.

METHODS

All children ≥37 weeks' gestation and <19 years old in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for ≥1 minute and invasive arterial blood pressure monitoring before and during CPR between July 1, 2013, and June 31, 2016, were included. Mean DBP during CPR and Utstein-style standardized cardiac arrest data were collected. The hypothesis was that DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old would be associated with survival. Primary outcome was survival to hospital discharge. Secondary outcome was survival to hospital discharge with favorable neurological outcome, defined as Pediatric Cerebral Performance Categories 1 to 3 or no worse than prearrest baseline. Multivariable Poisson regression models with robust error estimates were used to estimate the relative risk of outcomes.

RESULTS

Blinded investigators analyzed blood pressure waveforms during CPR from 164 children, including 60% <1 year old, 60% with congenital heart disease, and 54% after cardiac surgery. The immediate cause of arrest was hypotension in 67%, respiratory decompensation in 44%, and arrhythmia in 19%. Median duration of CPR was 8 minutes (quartiles, 3 and 27 minutes). Ninety percent survived the event, 68% with return of spontaneous circulation and 22% by extracorporeal life support. Forty-seven percent survived to hospital discharge, and 43% survived to discharge with favorable neurological outcome. Maintaining mean DBP ≥25 mm Hg in infants and ≥30 mm Hg in children ≥1 year old occurred in 101 of 164 children (62%) and was associated with survival (adjusted relative risk, 1.7; 95% confidence interval, 1.2-2.6; P=0.007) and survival with favorable neurological outcome (adjusted relative risk, 1.6; 95% confidence interval, 1.1-2.5; P=0.02).

CONCLUSIONS

These data demonstrate that mean DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old was associated with greater likelihood of survival to hospital discharge and survival with favorable neurological outcome.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Cardiopulmonary Resuscitation in Pediatric and Cardiac Intensive Care Units

Approximately 5000 to 10,000 children suffer an in-hospital cardiac arrest requiring cardiopulmonary resuscitation (CPR) each year in the United States. Importantly, 2% to 6% of all children admitted to pediatric intensive care units (ICUs) receive CPR, as do 4% to 6% of children admitted to pediatric cardiac ICUs. Survival from pediatric ICU cardiac arrest has improved substantially during the past 20 years presumably due to improved training methods, CPR quality, and post-resuscitation care. Extracorporeal life support CPR remains an important treatment option for both cardiac and noncardiac ICU patients.

Continuous capnography monitoring during resuscitation in a transitional large mammalian model of asphyxial cardiac arrest

BACKGROUND

In neonates requiring chest compression (CC) during resuscitation, neonatal resuscitation program (NRP) recommends against relying on a single feedback device such as end-tidal carbon dioxide (ETCO₂) or saturations (SpO₂) to determine return of spontaneous circulation (ROSC) until more evidence becomes available.

METHODS

We evaluated the role of monitoring ETCO₂ during resuscitation in a lamb model of cardiac arrest induced by umbilical cord occlusion (n = 21). Lambs were resuscitated as per NRP guidelines. Systolic blood pressure (SBP), carotid and pulmonary blood flows along with ETCO₂ and blood gases were continuously monitored. Resuscitation was continued for 20 min or until ROSC (whichever was earlier). Adequate CC was arbitrarily defined as generation of 30 mmHg SBP during resuscitation. ETCO₂ thresholds to predict adequacy of CC and detect ROSC were determined.

RESULTS

Significant relationship between ETCO₂ and adequate CC was noted during resuscitation (AUC-0.735, P < 0.01). At ROSC (n = 12), ETCO₂ rapidly increased to 57 ± 20 mmHg with a threshold of ≥32 mmHg being 100% sensitive and 97% specific to predict ROSC.

CONCLUSION

In a large mammalian model of perinatal asphyxia, continuous ETCO₂ monitoring predicted adequacy of CC and detected ROSC. These findings suggest ETCO₂ in conjunction with other devices may be beneficial during CC and predict ROSC.

Randomised crossover trial of rate feedback and force during chest compressions for paediatric cardiopulmonary resuscitation

OBJECTIVE

To determine the effect of visual feedback on rate of chest compressions, secondarily relating the forces used.

DESIGN

Randomised crossover trial.

SETTING

Tertiary teaching hospital.

SUBJECTS

Fifty trained hospital staff.

INTERVENTIONS

A thin sensor-mat placed over the manikin's chest measured rate and force. Rescuers applied compressions to the same paediatric manikin for two sessions. During one session they received visual feedback comparing their real-time rate with published guidelines.

OUTCOME MEASURES

Primary: compression rate. Secondary: compression and residual forces.

RESULTS

Rate of chest compressions (compressions per minute (compressions per minute; cpm)) varied widely (mean (SD) 111 (13), range 89-168), with a fourfold difference in variation during session 1 between those receiving and not receiving feedback (108 (5) vs 120 (20)). The interaction of session by feedback order was highly significant, indicating that this difference in mean rate between sessions was 14 cpm less (95% CI -22 to -5, p=0.002) in those given feedback first compared with those given it second. Compression force (N) varied widely (mean (SD) 306 (94); range 142-769). Those receiving feedback second (as opposed to first) used significantly lower force (adjusted mean difference -80 (95% CI -128 to -32), p=0.002). Mean residual force (18 N, SD 12, range 0-49) was unaffected by the intervention.

CONCLUSIONS

While visual feedback restricted excessive compression rates to within the prescribed range, applied force remained widely variable. The forces required may differ with growth, but such variation treating one manikin is alarming. Feedback technologies additionally measuring force (effort) could help to standardise and define effective treatments throughout childhood.

A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study

INTRODUCTION

Pediatric cardiac arrest is an uncommon but critical life-threatening event requiring effective cardiopulmonary resuscitation. High-quality cardio-pulmonary resuscitation (CPR) is essential, but is poorly performed, even by highly skilled healthcare providers. The recently described two-thumb chest compression technique (nTTT) consists of the two thumbs directed at the angle of 90° to the chest while having the fingers fist-clenched. This technique might facilitate adequate chest-compression depth, chest-compression rate and rate of full chest-pressure relief.

METHODS

42 paramedics from the national Emergency Medical Service of Poland performed three single-rescuer CPR sessions for 10 minutes each. Each session was randomly assigned to the conventional two-thumb (TTHT), the conventional two-finger (TFT) or the nTTT. The manikin used for this study was connected with an arterial blood pressure measurement device and blood measurements were documented on a 10-seconds cycle.

RESULTS

The nTTT provided significant higher systolic (82 vs. 30 vs. 41 mmHg). A statistically significant difference was noticed between nTTT and TFT (p<.001), nTTT and TTHT (p<0.001), TFT and TTHT (p=0.003). The median diastolic preassure using nTTT was 16 mmHg compared with 9 mmHg for TFT (p<0.001), and 9.5 mmHg for TTHT (p<0.001). Mean arterial pressure using distinct methods varied and amounted to 40 vs. 22. vs. 26 mmHg (nTTT vs. TFT vs. TTHT, respectively). A statistically significant difference was noticed between nTTT and TFT (p<0.001), nTTT and TTEHT (p<0.001), and TFT and TTHT (p<0.001). The highest median pulse pressure was obtained by the nTTT 67.5 mmHg. Pulse pressure was 31.5 mmHg in the TTHT and 24 mmHg in the TFT. The difference between TFT and TTHT (p=0.025), TFT and nTTT (p<0.001), as well as between TTHT and nTTT (p<0.001) were statistically significant.

CONCLUSIONS

The new nTTT technique generated higher arterial blood pressures compared to established chest compression techniques using an infant manikin model, suggesting a more effective chest compression. Our results have important clinical implications as nTTT was simple to perform and could be widely taught to both healthcare professionals and bystanders. Whether this technique translates to improved outcomes over existing techniques needs further animal studies and subsequent human trials.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Novel Nonlinear Mathematical Model of Thoracic Wall Mechanics During Cardiopulmonary Resuscitation Based on a Porcine Model of Cardiac Arrest

Cardiopulmonary resuscitation (CPR) is used widely to rescue cardiac arrest patients, yet some physiological aspects of the procedure remain poorly understood. We conducted this study to characterize the dynamic mechanical properties of the thorax during CPR in a swine model. This is an important step toward determining optimal CPR chest compression mechanics with the goals of improving the fidelity of CPR simulation manikins and ideally chest compression delivery in real-life resuscitations. This paper presents a novel nonlinear model of the thorax that captures the complex behavior of the chest during CPR. The proposed model consists of nonlinear elasticity and damping properties along with frequency dependent hysteresis. An optimization technique was used to estimate the model coefficients for force-compression using data collected from experiments conducted on swine. To track clinically relevant, time-dependent changes of the chest's properties, the data was divided into two time periods, from 1 to 10 min (early) and greater than 10 min (late) after starting CPR. The results showed excellent agreement between the actual and the estimated forces, and energy dissipation due to viscous damping in the late stages of CPR was higher when compared to the earlier stages. These findings provide insight into improving chest compression mechanics during CPR, and may provide the basis for developing CPR simulation manikins that more accurately represent the complex real world changes that occur in the chest during CPR.

Duration of Prehospital Cardiopulmonary Resuscitation and Favorable Neurological Outcomes for Pediatric Out-of-Hospital Cardiac Arrests: A Nationwide, Population-Based Cohort Study

BACKGROUND

The appropriate duration of cardiopulmonary resuscitation (CPR) for pediatric out-of-hospital cardiac arrests (OHCAs) remains unclear and may differ based on initial rhythm. We aimed to determine the relationship between the duration of prehospital CPR by emergency medical services (EMS) personnel and post-OHCA outcomes.

METHODS

We analyzed the records of 12 877 pediatric patients who experienced OHCAs (<18 years of age). Data were recorded in a nationwide Japanese database between 2005 and 2012. Study end points were 30-day survival and 30-day survival with favorable neurological outcomes (Cerebral Performance Category [CPC] scale 1-2). Prehospital EMS-initiated CPR duration was defined as the time from CPR initiation by EMS personnel to prehospital return of spontaneous circulation (ROSC) or to hospital arrival when prehospital ROSC was not achieved during prehospital CPR efforts.

RESULTS

The rates of 30-day survival and 30-day CPC 1 to 2 were 9.1% (n=1167) and 2.5% (n=325), respectively. Prehospital EMS-initiated CPR duration was significantly and inversely associated with 30-day outcomes (adjusted odds ratio for 1-minute increments: 0.94, 95% confidence interval: 0.93-0.95 for survival; adjusted odds ratio: 0.90, 95% confidence interval: 0.88-0.92 for CPC 1-2). The duration of prehospital EMS-initiated CPR, beyond which the chance for favorable outcomes diminished to <1%, was 42 minutes for each key outcome, 30-day survival, and 30-day survival with CPC 1 to 2. When categorized by initial rhythm, the prehospital EMS-initiated CPR durations beyond which the chance for 30-day survival with CPC 1 to 2 diminished to <1% were 39 minutes for shockable rhythms, 42 minutes for pulseless electric activity, and 46 minutes for asystole, respectively. In patients with bystander-initiated CPR, the prehospital CPR duration, beyond which the chance for favorable outcome diminished to <1%, was 46 minutes from call receipt.

CONCLUSIONS

Prehospital EMS-initiated CPR duration for pediatric OHCAs was independently and inversely associated with 30-day favorable outcomes. The duration of prehospital EMS-initiated CPR, beyond which the chance for 30-day favorable outcomes diminished to <1%, was 42 minutes. However, the CPR duration to achieve this proportion of outcomes differed based on initial rhythm. Further research is required to elucidate appropriate CPR duration for pediatric OHCAs, including in-hospital CPR time.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT02432196.

Blood Pressure Directed Booster Trainings Improve Intensive Care Unit Provider Retention of Excellent Cardiopulmonary Resuscitation Skills

OBJECTIVES

Brief, intermittent cardiopulmonary resuscitation (CPR) training sessions, "Booster Trainings," improve CPR skill acquisition and short-term retention. The objective of this study was to incorporate arterial blood pressure (ABP) tracings into Booster Trainings to improve CPR skill retention. We hypothesized that ABP-directed CPR "Booster Trainings" would improve intensive care unit (ICU) provider 3-month retention of excellent CPR skills without need for interval retraining.

METHODS

A CPR manikin creating a realistic relationship between chest compression depth and ABP was used for training/testing. Thirty-six ICU providers were randomized to brief, bedside ABP-directed CPR manikin skill retrainings: (1) Booster Plus (ABP visible during training and testing) versus (2) Booster Alone (ABP visible only during training, not testing) versus (3) control (testing, no intervention). Subjects completed skill tests pretraining (baseline), immediately after training (acquisition), and then retention was assessed at 12 hours, 3 and 6 months. The primary outcome was retention of excellent CPR skills at 3 months. Excellent CPR was defined as systolic blood pressure of 100 mm Hg or higher and compression rate 100 to 120 per minute.

RESULTS

Overall, 14 of 24 (58%) participants acquired excellent CPR skills after their initial training (Booster Plus 75% vs 50% Booster Alone, P = 0.21). Adjusted for age, ABP-trained providers were 5.2× more likely to perform excellent CPR after the initial training (95% confidence interval [95% CI], 1.3-21.2; P = 0.02), and to retain these skills at 12 hours (adjusted odds ratio, 4.4; 95% CI, 1.3-14.9; P = 0.018) and 3 months (adjusted odds ratio, 4.1; 95% CI, 1.2-13.9; P = 0.023) when compared to baseline performance.

CONCLUSIONS

The ABP-directed CPR booster trainings improved ICU provider 3-month retention of excellent CPR skills without the need for interval retraining.

Hospital variation in survival after pediatric in-hospital cardiac arrest

BACKGROUND

Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children,validated methods to risk-standardize pediatric survival rates across sites do not currently exist.

METHODS AND RESULTS

From 2006 to 2010, within the American Heart Association's Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1551 cardiac arrests in children (<18 years). Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge and calculated risk-standardized rates of cardiac arrest survival for hospitals with a minimum of 10 pediatric cardiac arrest cases. A total of 13 patient-level predictors were identified: age, sex, cardiac arrest rhythm, location of arrest, mechanical ventilation, acute nonstroke neurological event, major trauma, hypotension, metabolic or electrolyte abnormalities, renal insufficiency, sepsis, illness category, and need for intravenous vasoactive agents prior to the arrest. The model had good discrimination (C-statistic of 0.71), confirmed by bootstrap validation (validation C-statistic of 0.69). Among 30 hospitals with ≥10 cardiac arrests, unadjusted hospital survival rates varied considerably (median, 37%; interquartile range, 24-42%; range, 0-61%). After risk-standardization, the range of hospital survival rates narrowed (median, 37%; interquartile range, 33-38%; range, 29-48%), but variation in survival persisted.

CONCLUSIONS

Using a national registry, we developed and validated a model to predict survival after in-hospital cardiac arrest in children. After risk-standardization, significant variation in survival rates across hospitals remained. Leveraging these models, future studies can identify best practices at high-performing hospitals to improve survival outcomes for pediatric cardiac arrest. (

Simultaneous beat-to-beat assessment of arterial blood pressure and quality of cardiopulmonary resuscitation in out-of-hospital and in-hospital settings

OBJECTIVE

The current recommendation for depth and rate of chest compression (CC) during cardiopulmonary resuscitation (CPR) is based on limited hemodynamic data recorded during human CPR. We have evaluated the possible association between CC depth and rate and continuously measured arterial blood pressure during adult CPR.

METHODS

This prospective study included data from 104 patients resuscitated inside or outside hospital. Adequate data on continuously measured invasive arterial blood pressure (BP) and the quality of CPR from a defibrillator capable recording CPR quality parameters was successful in 39 patients. We used logistic regression and mixed effects modeling to identify CC depths and rates associated with systolic blood pressure (SBP) ≥ 85 mm Hg and diastolic blood pressure (DBP) ≥ 30 mm Hg.

RESULTS

We analyzed 41,575 compression-BP pairs. The values for blood pressure varied greatly between the patients. SBP varied from 25 to 225 mm Hg and DBP from 2 to 59 mm Hg. CC rate 100-120/min and CC depth ≥ 60 mm (without mattress deflection correction) was associated with DBP ≥ 30 mm Hg in both femoral (OR 1.14; 95% CI 1.03, 1.26; p<0.05) and radial (OR 4.70; 95% CI 3.92, 5.63; p<0.001) recordings. For any given subject there was a weak upward trend in blood pressure as CC depth increased.

CONCLUSION

Deeper CC does not equal higher BP in every patient. The heterogeneity of patients creates a challenge to find the optimal way to resuscitate patients individually.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT00951704.

Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes*

OBJECTIVE

In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.

DESIGN, SETTING, AND PATIENTS

Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.

INTERVENTIONS

Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).

CONCLUSION

Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest

Cardiopulmonary resuscitation (CPR) guidelines assume that cardiac arrest victims can be treated with a uniform chest compression (CC) depth and a standardized interval administration of vasopressor drugs. This non-personalized approach does not incorporate a patient's individualized response into ongoing resuscitative efforts. In previously reported porcine models of hypoxic and normoxic ventricular fibrillation (VF), a hemodynamic-directed resuscitation improved short-term survival compared to current practice guidelines. Skilled in-hospital rescuers should be trained to tailor resuscitation efforts to the individual patient's physiology. Such a strategy would be a major paradigm shift in the treatment of in-hospital cardiac arrest victims.

Virtual arterial blood pressure feedback improves chest compression quality during simulated resuscitation

INTRODUCTION

Quality chest compressions (CC) are the most important factor in successful cardiopulmonary resuscitation. Adjustment of CC based upon an invasive arterial blood pressure (ABP) display would be theoretically beneficial. Additionally, having one compressor present for longer than a 2-min cycle with an ABP display may allow for a learning process to further maximize CC. Accordingly, we tested the hypothesis that CC can be improved with a real-time display of invasively measured blood pressure and with an unchanged, physically fit compressor.

METHODS

A manikin was attached to an ABP display derived from a hemodynamic model responding to parameters of CC rate, depth, and compression-decompression ratio. The area under the blood pressure curve over time (AUC) was used for data analysis. Each participant (N=20) performed 4 CPR sessions: (1) No ABP display, exchange of compressor every 2 min; (2) ABP display, exchange of compressor every 2 min; (3) no ABP display, no exchange of the compressor; (4) ABP display, no exchange of the compressor. Data were analyzed by ANOVA. Significance was set at a p-value<0.05.

RESULTS

The average AUC for cycles without ABP display was 5201 mm Hgs (95% confidence interval (CI) of 4804-5597 mm Hgs), and for cycles with ABP display 6110 mm Hgs (95% CI of 5715-6507 mm Hgs) (p<0.0001). The average AUC increase with ABP display for each participant was 20.2±17.4% 95 CI (p<0.0001).

CONCLUSIONS

Our study confirms the hypothesis that a real-time display of simulated ABP during CPR that responds to participant performance improves achieved and sustained ABP. However, without any real-time visual feedback, even fit compressors demonstrated degradation of CC quality.

Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association

The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" increased the focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts. There are 5 critical components of high-quality CPR: minimize interruptions in chest compressions, provide compressions of adequate rate and depth, avoid leaning between compressions, and avoid excessive ventilation. Although it is clear that high-quality CPR is the primary component in influencing survival from cardiac arrest, there is considerable variation in monitoring, implementation, and quality improvement. As such, CPR quality varies widely between systems and locations. Victims often do not receive high-quality CPR because of provider ambiguity in prioritization of resuscitative efforts during an arrest. This ambiguity also impedes the development of optimal systems of care to increase survival from cardiac arrest. This consensus statement addresses the following key areas of CPR quality for the trained rescuer: metrics of CPR performance; monitoring, feedback, and integration of the patient's response to CPR; team-level logistics to ensure performance of high-quality CPR; and continuous quality improvement on provider, team, and systems levels. Clear definitions of metrics and methods to consistently deliver and improve the quality of CPR will narrow the gap between resuscitation science and the victims, both in and out of the hospital, and lay the foundation for further improvements in the future.

Advances in recognition, resuscitation, and stabilization of the critically ill child

Advances in early recognition, effective response, and high-quality resuscitation before, during, and after cardiac arrest have resulted in improved survival for infants and children over the past 10 years. This review addresses several key factors that can make a difference in survival outcomes, including the etiology of pediatric cardiac arrests in and out of hospital, mechanisms and techniques of circulation of blood flow during cardiopulmonary resuscitation (CPR), quality of CPR, meticulous postresuscitative care, and effective training. Monitoring and quality improvement of each element in the system of resuscitation care are increasingly recognized as key factors in saving lives.