Cardiopulmonary resuscitation: special considerations for infants and children with cardiac disease

Decision-centered design of a clinical decision support system for acute management of pediatric congenital heart disease

Background and Objectives

Children with congenital heart disease (CHD), have fragile hemodynamics and can deteriorate due to common childhood illnesses and the natural progression of their disease. During these acute periods of deterioration, these children often present to their local emergency departments (ED) where expertise in CHD is limited, and appropriate intervention is crucial to their survival. Previous studies identified that determining the appropriate intervention for CHD patients can be difficult for ED physicians, particularly since key components of effective decision making are not being met. Although key components of effective decision making for ED physicians have been identified, they have yet to be transformed into actionable guidance. We used decision centered design (DCD) to translate key components of decision making into decision requirements and associated design concepts, that we subsequently incorporated into a prototype clinical decision support system (CDSS).

Methods

Using framework analysis, transcripts from Critical Decision Method interviews of CHD experts and ED physicians were inductively coded to identify key decision requirements for ED physicians that are currently not well supported, and their associated design concepts. A design workshop was held to refine the identified key decision requirements and design concepts as well as to sketch information that would satisfy the identified requirements. These were iteratively incorporated into a prototype CDSS.

Results

Three decision requirements: (1) distinguish the patient's unique physiology based on their unique cardiac anatomy, (2) explicitly consider CHD specific differential diagnoses to allow a more structured reflection of diagnosis, and (3) select CHD appropriate interventions for each patient, were identified. These requirements along with design concepts and information needs identified through the design workshop were incorporated into the CDSS prototype.

Conclusion

We identified key decision requirements and associated design concepts, that informed the design of a CDSS to provide actionable guidance for ED physicians when managing CHD patients. Meeting ED physicians' decision components with a CDSS requires the translation of their key decision requirements in its design. If not, we risk creating designs that interfere with clinician performance.

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

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.

Standard CPR versus interposed abdominal compression CPR in shunted single ventricle patients: comparison using a lumped parameter mathematical model

INTRODUCTION

Cardiopulmonary resuscitation (CPR) in the shunted single-ventricle population is associated with poor outcomes. Interposed abdominal compression-cardiopulmonary resuscitation, or IAC-CPR, is an adjunct to standard CPR in which pressure is applied to the abdomen during the recoil phase of chest compressions.

METHODS

A lumped parameter model that represents heart chambers and blood vessels as resistors and capacitors was used to simulate blood flow in both Blalock-Taussig-Thomas and Sano circulations. For standard CPR, a prescribed external pressure waveform was applied to the heart chambers and great vessels to simulate chest compressions. IAC-CPR was modelled by adding phasic compression pressure to the abdominal aorta. Differential equations for the model were solved by a Runge-Kutta method.

RESULTS

In the Blalock-Taussig-Thomas model, mean pulmonary blood flow during IAC-CPR was 30% higher than during standard CPR; cardiac output increased 21%, diastolic blood pressure 16%, systolic blood pressure 8%, coronary perfusion pressure 17%, and coronary blood flow 17%. In the Sano model, pulmonary blood flow during IAC-CPR increased 150%, whereas cardiac output was improved by 13%, diastolic blood pressure 18%, systolic blood pressure 8%, coronary perfusion pressure 15%, and coronary blood flow 14%.

CONCLUSIONS

In this model, IAC-CPR confers significant advantage over standard CPR with respect to pulmonary blood flow, cardiac output, blood pressure, coronary perfusion pressure, and coronary blood flow. These results support the notion that single-ventricle paediatric patients may benefit from adjunctive resuscitation techniques, and underscores the need for an in-vivo trial of IAC-CPR in children.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study

BACKGROUND

The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation.

METHODS

This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants.

RESULTS

Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant's chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants' subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively.

CONCLUSIONS

The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively.

IMPACT

Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.

Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest

BACKGROUND

Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown.

METHODS

Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge.

RESULTS

Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85).

CONCLUSIONS

In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.

Brain Development of Children With Single Ventricle Physiology or Transposition of the Great Arteries: A Longitudinal Observation Study

To define the correlation between neuroanatomic and developmental outcomes of children with single ventricle (SV) or transposition of the great arteries (TGA), a prospective longitudinal study was performed in preschool and school-age children. Twenty-seven children with congenital heart disease (9, TGA; 18, SV) were included. Participants underwent 3-dimensional magnetic resonance imaging (MRI) and neurodevelopmental assessment at around 3 years (preschool age) and at 9 years (school age), and 48 healthy controls underwent MRI, and their data were used to derive best-fit models for normal brain volumes for comparisons with congenital heart disease patients. Total brain volume (TBV) and regional brain volumes remained significantly smaller in SV children than in TGA children at both time points, though the growth slope of TBV was not significantly different between the SV and TGA groups. Although the psychomotor developmental index at preschool was significantly lower in SV patients, the full-scale IQ at school age was not significantly lower in SV patients. There was a strong correlation between full-scale IQ and TBV (r = 0.49, P = 0.005). Despite the current best practices, persistently lower TBV was seen in SV patients until 9 years of age. For both the SV and TGA groups, TBV at 3 years was a strong predictor of TBV at 9 years. Since there was a correlation between TBV and IQ at 9 years, identification of factors that affect brain growth until 3 years will be imperative to improve patients' cognitive function at school age.

Cardiac Arrest in the Pediatric Cardiac ICU: Is Medical Congenital Heart Disease a Predictor of Survival?

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.

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.

Epidemiology and Outcomes of Cardiac Arrest in Pediatric Cardiac ICUs

OBJECTIVES

In-hospital cardiac arrest occurs in 2.6-6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about cardiac arrest in pediatric cardiac ICUs; therefore, we aimed to describe cardiac arrest epidemiology in a contemporary multicenter cardiac ICU cohort.

DESIGN

Retrospective analysis within the Pediatric Cardiac Critical Care Consortium clinical registry.

SETTING

Cardiac ICUs within 23 North American hospitals.

PATIENTS

All cardiac medical and surgical patients admitted from August 2014 to July 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 15,908 cardiac ICU encounters (6,498 medical, 9,410 surgical). 3.1% had cardiac arrest; rate was 4.8 cardiac arrest per 1,000 cardiac ICU days. Medical encounters had 50% higher rate of cardiac arrest compared with surgical encounters. Observed (unadjusted) cardiac ICU cardiac arrest prevalence varied from 1% to 5.5% among the 23 centers; cardiac arrest per 1,000 cardiac ICU days varied from 1.1 to 10.4. Over half cardiac arrest occur within 48 hours of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 4, 5 had strongest association with surgical encounter cardiac arrest. In medical encounters, independent cardiac arrest risk factors were acute heart failure, prematurity, lactic acidosis greater than 3 mmol/dL, and invasive ventilation 1 hour after admission. Median cardiopulmonary resuscitation duration was 10 minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal cardiopulmonary resuscitation in 27.2%. Unadjusted survival was 53.2% in encounters with cardiac arrest versus 98.2% without. Medical encounters had lower survival after cardiac arrest (37.7%) versus surgical encounters (62.5%); Norwood patients had less than half the survival after cardiac arrest (35.6%) compared with all others. Unadjusted survival after cardiac arrest varied greatly among 23 centers.

CONCLUSIONS

We provide contemporary epidemiologic and outcome data for cardiac arrest occurring in the cardiac ICU from a multicenter clinical registry. As detailed above, we highlight high-risk patient cohorts and periods of time that may serve as targets for research and quality improvement initiatives aimed at cardiac arrest prevention.

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.

Acute Decompensation in Pediatric Cardiac Patients: Outcomes After Rapid Response Events

OBJECTIVE

We studied rapid response events after acute clinical instability outside ICU settings in pediatric cardiac patients. Our objective was to describe the characteristics and outcomes after rapid response events in this high-risk cohort and elucidate the cardiac conditions and risk factors associated with worse outcomes.

DESIGN

A retrospective single-center study was carried out over a 3-year period from July 2011 to June 2014.

SETTING

Referral high-volume pediatric cardiac center located within a tertiary academic pediatric hospital.

PATIENTS

All rapid response events that occurred during the study period were reviewed to identify rapid response events in cardiac patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We reviewed 1,906 rapid response events to identify 152 rapid response events that occurred in 127 pediatric cardiac patients. Congenital heart disease was the baseline diagnosis in 74% events (single ventricle, 28%; biventricle physiology, 46%). Seventy-four percent had a cardiac surgery before rapid response, 37% had ICU stay within previous 7 days, and acute kidney injury was noted in 41% post rapid response. Cardiac and/or pulmonary arrest occurred during rapid response in 8.5%. Overall, 81% were transferred to ICU, 22% had critical deterioration (ventilation or vasopressors within 12 hr of transfer), and 56% received such support and/or invasive procedures within 72 hours. Mortality within 30 days post event was 14%. Significant outcome associations included: single ventricle physiology-increased need for invasive procedures and mortality (adjusted odds ratio, 2.58; p = 0.02); multiple rapid response triggers-increased ICU transfer and interventions at 72 hours; critical deterioration-cardiopulmonary arrest and mortality; and acute kidney injury-cardiopulmonary arrest and need for hemodynamic support.

CONCLUSIONS

Congenital heart disease, previous cardiac surgery, and recent discharge from ICU were common among pediatric cardiac rapid responses. Progression to cardiopulmonary arrest during rapid response, need for ICU care, kidney injury after rapid response, and mortality were high. Single ventricle physiology was independently associated with increased mortality.

Near-infrared spectroscopy as a predictor of clinical deterioration: a case report of two infants with duct-dependent congenital heart disease

Background

Some infants with congenital heart disease are at risk of in-hospital cardiac arrest. To better foresee cardiac arrest in infants with congenital heart disease, it might be useful to continuously assess end-organ perfusion. Near-infrared spectroscopy is a non-invasive method to continuously assess multisite regional tissue oxygen saturation.

Case presentation

We report on two infants with duct-dependent congenital heart disease who demonstrated a gradual change in cerebral and/or renal tissue oxygen saturation before cardiopulmonary resuscitation was required. In both cases, other clinical parameters such as heart rate, arterial oxygen saturation and blood pressure did not indicate that deterioration was imminent.

Conclusions

These two cases demonstrate that near-infrared spectroscopy might contribute to detecting a deteriorating clinical condition and might therefore be helpful in averting cardiopulmonary collapse and need for resuscitation in infants with congenital heart disease.

Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs

OBJECTIVES

To determine the incidence of cardiopulmonary resuscitation in PICUs and subsequent outcomes.

DESIGN, SETTING, AND PATIENTS

Multicenter prospective observational study of children younger than 18 years old randomly selected and intensively followed from PICU admission to hospital discharge in the Collaborative Pediatric Critical Care Research Network December 2011 to April 2013.

RESULTS

Among 10,078 children enrolled, 139 (1.4%) received cardiopulmonary resuscitation for more than or equal to 1 minute and/or defibrillation. Of these children, 78% attained return of circulation, 45% survived to hospital discharge, and 89% of survivors had favorable neurologic outcomes. The relative incidence of cardiopulmonary resuscitation events was higher for cardiac patients compared with non-cardiac patients (3.4% vs 0.8%, p <0.001), but survival rate to hospital discharge with favorable neurologic outcome was not statistically different (41% vs 39%, respectively). Shorter duration of cardiopulmonary resuscitation was associated with higher survival rates: 66% (29/44) survived to hospital discharge after 1-3 minutes of cardiopulmonary resuscitation versus 28% (9/32) after more than 30 minutes (p < 0.001). Among survivors, 90% (26/29) had a favorable neurologic outcome after 1-3 minutes versus 89% (8/9) after more than 30 minutes of cardiopulmonary resuscitation.

CONCLUSIONS

These data establish that contemporary PICU cardiopulmonary resuscitation, including long durations of cardiopulmonary resuscitation, results in high rates of survival-to-hospital discharge (45%) and favorable neurologic outcomes among survivors (89%). Rates of survival with favorable neurologic outcomes were similar among cardiac and noncardiac patients. The rigorous prospective, observational study design avoided the limitations of missing data and potential selection biases inherent in registry and administrative data.

Extracorporeal membrane oxygenation in patients undergoing superior cavopulmonary anastomosis

OBJECTIVE

Patients who have undergone the superior cavopulmonary anastomosis (Glenn procedure) have unique cardiopulmonary-cerebral physiology that may limit the success of cardiopulmonary resuscitation and extracorporeal membrane oxygenation (ECMO). Limited data published to date suggest grim morbidity and mortality when ECMO is used. We utilized the Extracorporeal Life Support Organization registry database to more thoroughly assess outcomes in these patients.

METHODS

Data from the Extracorporeal Life Support Organization registry from 1999 to 2012 for children with Glenn physiology aged 3 months to 1 year were retrospectively analyzed. Demographics and ECMO characteristics were compared between survivors and nonsurvivors. Factors associated with mortality were evaluated using multivariate logistic regression.

RESULTS

Of 103 infants, 42 (41%) survived to hospital discharge. Neurologic complications (eg, seizure, hemorrhage, or embolic stroke) were documented in 23% of patients (24 of 103) and 14% of survivors (6 of 42). In univariate analysis, inotropic requirement before ECMO, duration of ECMO, mechanical complications with the ECMO circuit, renal failure, and pulmonary hemorrhage or pneumothorax were predictors of mortality. In multivariate logistic regression, inotrope requirement (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.3-9.8), longer duration of ECMO support (OR, 7.2; 95% CI, 1.8-28), combined cardiopulmonary indication for ECMO (OR, 3.7; 95% CI, 1.4-9.7), and renal failure (OR, 4.2; 95% CI, 1.5-12) were associated with mortality.

CONCLUSIONS

Mortality in infants with Glenn physiology supported with ECMO is lower than that previously reported, but the incidence of neurologic injury is high. These data support use of ECMO in patients with Glenn physiology with refractory cardiopulmonary failure.

Near-infrared spectroscopy: exposing the dark (venous) side of the circulation

The safety of anesthesia has improved greatly in the past three decades. Standard perioperative monitoring, including pulse oximetry, has practically eliminated unrecognized arterial hypoxia as a cause for perioperative injury. However, most anesthesia-related cardiac arrests in children are now cardiovascular in origin, and standard monitoring is unable to detect many circulatory abnormalities. Near-infrared spectroscopy provides noninvasive continuous access to the venous side of regional circulations that can approximate organ-specific and global measures to facilitate the detection of circulatory abnormalities and drive goal-directed interventions to reduce end-organ ischemic injury.

Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing

OBJECTIVES

The aim of this study was to evaluate the relative frequency of pediatric in-hospital cardiopulmonary resuscitation events occurring in ICUs compared to general wards. We hypothesized that the proportion of pediatric cardiopulmonary resuscitation provided in ICUs versus general wards has increased over the past decade, and this shift is associated with improved resuscitation outcomes.

DESIGN

Prospective and observational study.

SETTING

Total of 315 hospitals in the American Heart Association's Get With The Guidelines-Resuscitation database.

PATIENTS

Total of 5,870 pediatric cardiopulmonary resuscitation events between January 1, 2000 and September 14, 2010. Cardiopulmonary resuscitation events were defined as external chest compressions longer than 1 minute.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was proportion of total ICU versus general ward cardiopulmonary resuscitation events over time evaluated by chi-square test for trend. Secondary outcome included return of spontaneous circulation following the cardiopulmonary resuscitation event. Among 5,870 pediatric cardiopulmonary resuscitation events, 5,477 (93.3%) occurred in ICUs compared to 393 (6.7%) in inpatient wards. Over time, significantly more of these cardiopulmonary resuscitation events occurred in the ICU compared to the wards (test for trend: p<0.01), with a prominent shift noted between 2003 and 2004 (2000-2003: 87-91% vs 2004-2010: 94-96%). In a multivariable model controlling for within center variability and other potential confounders, return of spontaneous circulation increased in 2004-2010 compared with 2000-2003 (relative risk, 1.08; 95% CI, 1.03-1.13).

CONCLUSIONS

In-hospital pediatric cardiopulmonary resuscitation is much more commonly provided in ICUs than in wards, and the proportion has increased significantly over the past decade, with concomitant increases in return of spontaneous circulation.

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.

Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association

BACKGROUND

The goal of this statement was to review the available literature on surveillance, screening, evaluation, and management strategies and put forward a scientific statement that would comprehensively review the literature and create recommendations to optimize neurodevelopmental outcome in the pediatric congenital heart disease (CHD) population.

METHODS AND RESULTS

A writing group appointed by the American Heart Association and American Academy of Pediatrics reviewed the available literature addressing developmental disorder and disability and developmental delay in the CHD population, with specific attention given to surveillance, screening, evaluation, and management strategies. MEDLINE and Google Scholar database searches from 1966 to 2011 were performed for English-language articles cross-referencing CHD with pertinent search terms. The reference lists of identified articles were also searched. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. A management algorithm was devised that stratified children with CHD on the basis of established risk factors. For those deemed to be at high risk for developmental disorder or disabilities or for developmental delay, formal, periodic developmental and medical evaluations are recommended. A CHD algorithm for surveillance, screening, evaluation, reevaluation, and management of developmental disorder or disability has been constructed to serve as a supplement to the 2006 American Academy of Pediatrics statement on developmental surveillance and screening. The proposed algorithm is designed to be carried out within the context of the medical home. This scientific statement is meant for medical providers within the medical home who care for patients with CHD.

CONCLUSIONS

Children with CHD are at increased risk of developmental disorder or disabilities or developmental delay. Periodic developmental surveillance, screening, evaluation, and reevaluation throughout childhood may enhance identification of significant deficits, allowing for appropriate therapies and education to enhance later academic, behavioral, psychosocial, and adaptive functioning.

Probability of survival based on etiology of cardiopulmonary arrest in pediatric patients

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.

Bedside emergency cardiac ultrasound in children

Bedside emergency ultrasound has rapidly developed over the past several years and has now become part of the standard of care for several applications. While it has only recently been applied to critically ill pediatric patients, several of the well-established adult indications may be applied to pediatric patients. One of the most important and life-saving applications is bedside echocardiography. While bedside emergency ultrasonography does not serve to replace formal comprehensive studies, it serves as an extension of the physical examination. It is especially useful as a rapid and effective tool in the diagnosis of pericardial effusions, tamponade and in distinguishing potentially reversible causes of pulseless electrical activity from asystole. Most recently, left ventricular function and inferior vena cava measurements have proven helpful in the assessment of undifferentiated hypotension and shock in adults and children. Future research remains to be carried out in determining the efficacy of bedside ultrasonography in pediatric-specific pathology such as congenital heart disease. This article serves as a comprehensive review of the adult literature and a review of the recent applications in the pediatric emergency department. It also highlights the techniques of bedside ultrasonography with examples of normal and pathologic images.

Postcardiac arrest syndrome: focus on the brain

PURPOSE OF REVIEW

The field of pediatric cardiac arrest experienced recent advances secondary to multicenter collaborations. This review summarizes developments during the last year and identifies areas for further research.

RECENT FINDINGS

A large retrospective review demonstrated important differences in cause, severity, and outcome of in-hospital vs. out-of-hospital pediatric cardiac arrest. This distinction is relevant to interpretation of retrospective studies that may not distinguish between these entities, and in planning therapeutic clinical trials. Hypothermia was further evaluated as a treatment strategy after neonatal hypoxia and leaders in the field of neonatology recommend universal use of hypothermia in term neonates at risk. In infants and children after cardiac arrest, there are inadequate data to make a specific recommendation. Two retrospective studies evaluating hypothermia in children after cardiac arrest found that it tended to be administered more frequently to sicker patients. However, similar or worse outcomes of patients treated with hypothermia were observed. Use of extracorporeal membrane oxygenation is another emerging area of research in pediatric cardiac arrest, and surprisingly good outcomes have been seen with this modality in some cases.

SUMMARY

Therapeutic hypothermia and extracorporeal membrane oxygenation continue to be the only treatment modalities over and above conventional care for pediatric cardiac arrest. New approaches to monitoring, treatment, and rehabilitation after cardiac arrest remain to be explored.

Neonatal resuscitation in the ward: the role of nurses

Cardiopulmonary resuscitation (CPR) is necessary in about 1-2% of all newly born infants in their first minutes of life. However, CPR may also be needed in newborns beyond the time of birth, particularly in high risk categories of infants admitted in the NICU or in other less specialised units. In all these scenarios, the role of nurses is essential for several aspects, including early recognition of a deteriorating infant, with the aim to prevent cardiac arrest, as well as the starting of immediate basic life support manoeuvres at the bedside, whenever needed. Furthermore, nurses have a special part in family care during cardiopulmonary resuscitation.

Outcome following cardiopulmonary arrest

This article summarizes the current state of outcomes and outcome predictors following pediatric cardiopulmonary arrest with special emphasis on neurologic outcome. The authors briefly describe the factors associated with outcome and review clinical signs, electrophysiology, neuroimaging, and biomarkers used to predict outcome after cardiopulmonary arrest. Although clinical signs, imaging, and somatosensory evoked potentials are best associated with outcome, there are limited data to guide clinicians. Combinations of these predictors will most likely improve outcome prediction, but large-scale outcome studies are needed to better define these predictors.