Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States

Multi-dimensional outcomes following extracorporeal cardiopulmonary resuscitation

Background

Recent trials suggested that extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (VA-ECMO plus Impella®) may improve short-term survival and neurological outcomes in selected patients with refractory cardiac arrest. However, long-term effects on cardiac, cognitive, physical and psychological health need further study. A multidisciplinary post-ECPR outpatient care program was developed at two centers, involving cardiologists, neurologists, psychologists and medical sociologists to assess seven key health dimensions.

Methods

This bicentric, multidisciplinary study, conducted from May 2021 to April 2023, included adult ECPR survivors. Outcomes were assessed approximately 22 months post-cardiac arrest, focusing on cardiac, neurological, psychological and multi-organ functions, as well as social, professional and physical performance.

Results

This study included 33 ECPR survivors, who were predominantly male (70%) with a mean age of 55 years. Left-ventricular ejection fraction improved significantly, from 22% during ICU stay to 51% at follow-up in the ECMELLA group and from 31% to 51% in the VA-ECMO group (p = 0.006). Many patients reported dizziness or dyspnea (>52%) during daily activities, with a median New York Heart Association class of 2, EQ-5D-5L score of 53 and elevated NT-proBNP levels. Despite normal neurological scores, 46% had memory issues, 39% struggled with daily organization, 52% had depression and 12% had suicidal thoughts. Physical performance was reduced, with a mean distance of 394 meters in the 6-minute walk test and a 6-minute bicycle ergometry time.

Conclusion

ECPR patients showed significant improvement in left ventricular function over time but their neuropsychological and physical abilities remained compromised. Timely, multidisciplinary rehabilitation is required, starting in the intensive care unit and extending to include psychological support and community reintegration strategies after discharge.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of End-Tidal Carbon Dioxide Values in ICU Patients with and Without In-Hospital Cardiac Arrest

Objective: The purpose of this study was to evaluate the utility of end-tidal carbon dioxide (ETCO2) values as a predictive marker of in-hospital cardiac arrest (IHCA). This was achieved by comparing the trends of ETCO2 values in mechanically ventilated ICU patients that experienced an IHCA versus patients that did not. Methods: A single-center, retrospective, observational, and comparative cohort study at an academic medical center. Mechanically ventilated adults in the ICU who received continuous ETCO2 monitoring were included. Patients who were transferred to our facility already intubated, experienced an out-of-hospital cardiac arrest, or had a do-not-resuscitate order were excluded. Extracted data points included demographics, comorbidities, vitals, labs, and outcomes. Patients were grouped into IHCA and non-IHCA cohorts, and the trends of ETCO2 values were compared at multiple time points for 48 h before the IHCA or after intubation (time zero) for the groups, respectively. An ROC curve was constructed to determine the predictive value of ETCO2 for IHCA. Results: A total of 207 patients were included, of which 104 (50.2%) had an IHCA and 103 (49.8%) did not. There were no differences in the mean SOFA scores at the initiation of mechanical ventilation (8.5 vs. 7.6). The ETCO2 values were decreased in the IHCA cohort, and significantly different at each time point analyzed from 300 min until immediately prior to the arrest (p < 0.001). The ETCO2 values were a mean of 20.0 mmHg in the IHCA cohort at the index time vs. 34.7 mmHg in the non-IHCA cohort (p < 0.001). The ROC analysis demonstrated moderate reliability, with an AUC = 0.687 (p < 0.0001, 95% CI 0.613-0.761) and with an ETCO2 of less than 23 mmHg, demonstrating a 67% sensitivity and a 71% specificity, as well as a 70% PPV for predicting the IHCA from our sample. Conclusions: Patients typically have rapid clinical deteriorations prior to cardiac arrest, and monitoring ETCO2 is easily achieved at the bedside while aiding in clinical decision making. The ETCO2 values in our study were significantly decreased in the IHCA cohort prior to cardiac arrest compared to the stable values in those that did not experience an IHCA, indicating that ETCO2 monitoring may have utility in predicting cardiac arrest. Further study is warranted to evaluate if predictive models utilizing ETCO2 can be constructed to predict IHCAs in mechanically ventilated ICU patients.

Multi-omics Study of Hypoxic-Ischemic Brain Injury After Cardiopulmonary Resuscitation in Swine

BACKGROUND

Hypoxic-ischemic brain injury is a common cause of mortality after cardiac arrest (CA) and cardiopulmonary resuscitation; however, the specific underlying mechanisms are unclear. This study aimed to explore postresuscitation changes based on multi-omics profiling.

METHODS

A CA swine model was established, and the neurological function was assessed at 24 h after resuscitation, followed by euthanizing animals. Their fecal, blood, and hippocampus samples were collected to analyze gut microbiota, metabolomics, and transcriptomics.

RESULTS

The 16S ribosomal DNA sequencing showed that the microbiota composition and diversity changed after resuscitation, in which the abundance of Akkermansia and Muribaculaceae_unclassified increased while the abundance of Bifidobacterium and Romboutsia decreased. A relationship was observed between CA-related microbes and metabolites via integrated analysis of gut microbiota and metabolomics, in which Escherichia-Shigella was positively correlated with glycine. Combined metabolomics and transcriptomics analysis showed that glycine was positively correlated with genes involved in apoptosis, interleukin-17, mitogen-activated protein kinases, nuclear factor kappa B, and Toll-like receptor signal pathways.

CONCLUSIONS

Our results provided novel insight into the mechanism of hypoxic-ischemic brain injury after resuscitation, which is envisaged to help identify potential diagnostic and therapeutic markers.

Predictive value analysis of albumin-related inflammatory markers for short-term outcomes in patients with In-hospital cardiac arrest

OBJECTIVE

This study investigated the predictive value of albumin-related inflammatory markers for short-term outcomes in in-hospital cardiac arrest (IHCA) patients.

METHODS

A linear mixed model investigated the dynamic changes of markers within 72 hours after return of spontaneous circulation (ROSC). Time-Dependent COX regression explored the predictive value. Mediation analysis quantified the association of markers with organ dysfunctions and adverse outcomes.

RESULTS

Prognostic Nutritional Index (PNI) and RDW-Albumin Ratio (RAR) slightly changed (p > 0.05). Procalcitonin-Albumin Ratio (PAR1) initially increased and then slowly decreased. Neutrophil-Albumin Ratio (NAR) and Platelet-Albumin Ratio (PAR2) decreased slightly during 24-48 hours (all p<0.05). PNI (HR = 1.646, 95%CI (1.033,2.623)), PAR1 (HR = 1.69, 95%CI (1.057,2.701)), RAR (HR = 1.752,95%CI (1.103,2.783)) and NAR (HR = 1.724,95%CI (1.078,2.759)) were independently associated with in-hospital mortality. PNI (PM = 45.64%, 95%CI (17.05%,87.02%)), RAR (PM = 45.07%,95%CI (14.59%,93.70%)) and NAR (PM = 46.23%,95%CI (14.59%,93.70%)) indirectly influenced in-hospital mortality by increasing SOFA (central) scores. PNI (PM = 21.75%, 95%CI(0.67%,67.75%)) may also indirectly influenced outcome by increasing SOFA (renal) scores (all p < 0.05).

CONCLUSIONS

Within 72 hours after ROSC, albumin-related inflammatory markers (PNI, PAR1, RAR, and NAR) were identified as potential predictors of short-term prognosis in IHCA patients. They may mediate the adverse outcomes of patients by causing damages to the central nervous system and renal function.

Prevalence, outcome and conduct of in-hospital cardiopulmonary resuscitation in government hospitals of Nepal

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is an evidence-based intervention that saves lives. In low- and middle-income countries like Nepal, the occurrence of the problem and its outcome are seldom studied. The study aims to highlight the prevalence, performance, and outcome of CPR in government hospitals of Nepal.

METHODS

A mixed method study was done for two months in central and provincial government hospitals of Nepal. A total of 80 resuscitations were evaluated using a questionnaire based on the American Heart Association 2020 guidelines for cardiopulmonary resuscitation. An in-depth interview was conducted with 15 active participants of the resuscitation in different sites. Thematic analysis was done using the framework of the chain of survival of arrest victims.

RESULTS

The overall prevalence of CPR was found to be 1.92% [95% CI: 0.01,0.02] with 5.4% in central hospitals and 0.65% in provincial hospitals with 60% cardiac arrests occurring in the intensive care unit. Estimated time from recognition of the arrest to initiating CPR was 1.9 ±1.4 minutes. Asystole 66.25% was the commonest arrest rhythm and 21.25% had difficulty interpreting rhythm. Only 11.25% of the victims had return of spontaneous circulation and were subsequently transferred for post-arrest care. The qualitative analysis highlighted the lack of trained staff, a dedicated system, feedback mechanism, and provision of post-arrest care.

CONCLUSION

Across various level of Nepal's healthcare system, cardiopulmonary resuscitation is prevalent with poor performance and outcome. To improve outcomes, it is essential to implement standardized procedures and ensure high quality resuscitation delivery before and after the event supported by well-trained healthcare personnel and adequate infrastructure.

Factors Influencing Self-Confidence and Educational Needs in Electrocardiographic Monitoring Among Emergency Room and Intensive Care Unit Nurses

The self-confidence of nurses in performing electrocardiographic (ECG) monitoring is a critical competency for managing patients with cardiac conditions in high-acuity settings such as emergency rooms (ERs) and intensive care units (ICUs). This study aimed to identify the factors influencing nurses' confidence in ECG monitoring and to assess their educational needs. A total of 153 ER and ICU nurses participated in this cross-sectional study, completing structured questionnaires assessing their knowledge, confidence, and educational needs regarding ECG monitoring. The findings revealed a moderate mean confidence score of 63.47 (±15.09) out of 100. The key factors associated with higher confidence included the completion of ECG-related education, frequency of evidence searching, and clinical experience within the current department. Additionally, nurses prioritized eight critical educational topics for improving ECG-monitoring competency. These results underscore the importance of tailored educational programs and systematic training strategies to address identified gaps in knowledge and confidence. By prioritizing the specific needs of ER and ICU nurses, healthcare systems can foster supportive work environments, enhance nursing practice, and ultimately improve patient outcomes. Future research should evaluate the long-term impact of educational interventions on nurses' performance and clinical outcomes.

Longitudinal analysis of in-hospital cardiac arrest: trends in the incidence, mortality, and long-term survival of a nationwide cohort

BACKGROUND

In-hospital cardiac arrest (IHCA) poses a considerable threat to hospitalized patients, leading to high mortality rates and severe neurological deficits among survivors. Despite the advancements in resuscitation practices, the prognosis of IHCA remains poor, and comprehensive studies exploring nationwide trends and long-term survival are scarce, particularly in the Asian populations.

METHODS

Utilizing data from the Taiwan National Health Insurance Research Database, we conducted a nationwide cohort study to analyze the IHCA events among adult patients between 2003 and 2020. The outcomes of interest in this study included the temporal trend in the IHCA incidence, in-hospital mortality, and median survival after discharge for overall hospitalizations.

RESULTS

Over the 18-year period, the IHCA incidence in Taiwan declined by 70%, from an annual incidence of 7.1 per 1,000 admissions to a lower rate in 2020, accompanied by a 14% reduction in the in-hospital mortality rate, with an average of 86.5%. The overall long-term survival rate for discharged survivors was 63.9%. We observed a substantial 125% increase in the median survival duration of discharged survivors, rising from 1.56 years in 2003 to 3.51 years in 2015. Favorable in-hospital survival rates and extended life expectancy were notably seen in the patients with shockable rhythms, those with a cardiac primary diagnosis, women, and younger patients.

CONCLUSIONS

Our study data revealed significant declines in the IHCA incidence and in-hospital mortality in Taiwan, along with improved long-term survival among survivors, particularly among specific subgroups. Women exhibited significantly better long-term survival as compared to men, underscoring the need to avoid sex-based treatment biases. Improvements in discharge survival rates and life expectancy were less pronounced in older survivors, indicating that age alone may not be sufficient to guide IHCA management decisions. Proactive resuscitation should be carefully considered for older patients, particularly those with mild frailty and potentially reversible conditions. Trial registration the institutional review board of Chang Gung Memorial Hospital approved all data usage and the study protocol (Registration number: 202301625B0, Registered 7 November 2023).

Survival Differences in Asian and Hispanic Patients With In-Hospital Cardiac Arrest

BACKGROUND

Although they are fast-growing populations in the United States, little is known about survival outcomes of Hispanic and Asian patients after in-hospital cardiac arrest.

METHODS AND RESULTS

In Get With The Guidelines-Resuscitation, we identified Asian, Hispanic, and White adults with in-hospital cardiac arrest during 2005 to 2023. Using multivariable models, we compared rates of survival to discharge separately for Asian and Hispanic patients versus White patients, as well as rates of sustained return of spontaneous circulation for ≥20 minutes and favorable neurologic survival as secondary outcomes. Of 189 557 in-hospital cardiac arrests, 167 640 (88.4%), 16 800 (8.9%), and 5117 (2.7%) patients were White, Hispanic, and Asian, respectively. Compared with the survival rate to discharge for White patients (22.0%), rates were lower for Hispanic (19.4%; adjusted odds ratio [OR], 0.93 [95% CI, 0.89-0.97]; P<0.001) and Asian patients (17.8%; adjusted OR, 0.90 [95% CI, 0.83-0.97]; P=0.008), and these differences were attenuated after accounting for the hospital at which patients received care (adjusted OR: Hispanic patients, 0.95 [95% CI, 0.91-1.00]; Asian patients, 0.91 [95% CI, 0.84-0.99]). Although there were no differences in rates of return of spontaneous circulation between White (68.7%), Hispanic (69.0%), and Asian patients (69.7%), both Asian and Hispanic patients were less likely to have favorable neurologic survival (White: 18.3%; Hispanic: 15.4%; adjusted OR, 0.88 [95% CI, 0.84-0.93]; Asian: 13.2%; adjusted OR, 0.80 [95% CI, 0.73-0.87]). These differences were also attenuated after accounting for hospital site.

CONCLUSIONS

Compared with White patients, Hispanic and Asian patients with in-hospital cardiac arrest had lower rates of overall survival and favorable neurologic survival. Some of these differences were associated with the hospital at which patients received care.

Cardiopulmonary resuscitation coaching for resuscitation teams: A systematic review

Aim

Cardiopulmonary resuscitation (CPR) quality is often substandard to guidelines for resuscitation teams. We aimed to investigate if the use of a CPR coach as part of the resuscitation team can improve teamwork, quality of care, and patient outcomes during simulated and clinical cardiac arrest resuscitation.

Methods

We searched PubMed, Embase, and Cochrane from inception until October 9, 2024 for randomized trials and observational studies. We assessed risk of bias using Cochrane tools and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. PROSPERO CRD42024603212.

Results

We screened 505 records and included 7 studies. Overall, 6 were randomized studies involving pediatric resuscitation of which 4 studies were secondary analyses of one simulation-based trial, and one was an observational study on adult out-of-hospital cardiac arrest. Reported outcomes were: CPR performance in a simulated setting (n = 3), workload in a simulated setting (n = 2), adherence to guidelines in a simulated setting (n = 1), team communication in a simulated setting (n = 1), and clinical CPR performance (n = 1). All studies suggested improved CPR quality and guideline adherence when using a CPR coach compared to not using a coach. Risk of bias varied from low to critical and the certainty of evidence across outcomes was low or very low.

Conclusions

We identified low- to very-low certainty of evidence supporting the use of a CPR coach as part of the resuscitation team in order to improve CPR quality and guideline adherence. However, further research is needed, in particular for clinical performance and patient outcomes.

Do-not-attempt resuscitation policy reduced in-hospital cardiac arrest rate and the cost of care in a developing country

We aim to study the characteristics and outcomes of patients with a Do-Not-Attempt Resuscitation and to determine its impact on the Cost of In-Hospital Cardiac Arrest. A retrospective study of all adult patients admitted to the hospital from June 2021 to May 2022 who had a Do-Not-Resuscitate order. We abstracted patients' socio-demographics, physiologic parameters, primary diagnosis, and comorbidities from the electronic medical records. We calculated the potential economic cost using the median ICU length of stay for the admitted IHCA patients during the study period. There were 28,866 acute admissions over the study period, and 788 patients had DNR orders. The median (IQR) age was 71 (55-82) years, and 50.3% were males. The most prevalent primary diagnosis was sepsis, 426 (54.3%), and cancer was the most common comorbidity. More than one comorbidities were present in 642 (80%) of the cohort. Of the DNR patients, 492 (62.4%) died, while 296 (37.6%) survived to discharge. Cancer was the primary diagnosis in 65 (22.2%) of those who survived, compared with 154 (31.3%) of those who died (P = 0.002). Over the study period, 153 patients had IHCA and underwent CPR, with an IHCA rate of 5.3 per 1,000 hospital admissions. Without a DNR policy, an additional 492 patients with cardiac arrest would have had CPR, resulting in an IHCA rate of 22.3 per 1000 hospital admissions. Most DNR patients in our setting had sepsis complicated by multiple comorbidities. The DNR policy reduced our IHCA incidence by 76% and prevented unnecessary post-resuscitation ICU care.

Incidence and outcomes of in-hospital resuscitation for cardiac arrest among paediatric patients in Jordan: a retrospective observational study

OBJECTIVE

To investigate the incidence and survival rates of paediatric patients receiving resuscitation for in-hospital cardiac arrest (IHCA) in a teaching hospital in Northern Jordan, comparing initial pulseless rhythms and bradycardia rhythm with poor perfusion.

DESIGN

Retrospective observational study SETTING: An university-affiliated tertiary hospital in Northern Jordan, covering January 2015 to December 2022.

PATIENTS

All hospitalised paediatric patients aged 1 month-18 years who received cardiopulmonary resuscitation (CPR) for cardiac arrest were included in the study. Resuscitation attempts were categorised into initial pulseless rhythm events and bradycardia with poor perfusion events.

MAIN OUTCOME MEASURES

Incidence rate of paediatric CPR and the survival to hospital discharge rate.

RESULTS

A total of 504 paediatric patients received CPR during the study period, with an incidence rate of 6.26 per 1000 paediatric admissions. The annual incidence rate was significantly reduced by an average of 5.5% for the total sample but increased by 25.0% for bradycardia events (n=110, 21.8%). The percentage of patients who sustained return of spontaneous circulation (ROSC) was 25.0%. Survival to hospital discharge was low at 4.8% while showing an increasing trend by an average of 24.0% per year. Bradycardia events had a significantly higher ROSC rate (34.6% vs 22.3%); but an insignificant higher survival rate (6.4 vs 4.3). Patients with neurological or cardiovascular medical conditions, those in non-intensive care unit departments, and those with respiratory causes had higher odds of survival to discharge.

CONCLUSION

While the incidence rate of paediatric IHCA in Jordan is comparable to developed countries, the survival rate is much poorer. The study highlights the importance of strengthening healthcare infrastructure, establishing national legal and ethical frameworks around resuscitation policies and establishing robust data registries to monitor and optimise care practices.

Prediction of Survival After Pediatric Cardiac Arrest Using Quantitative EEG and Machine Learning Techniques

BACKGROUND AND OBJECTIVES

Early neuroprognostication in children with reduced consciousness after cardiac arrest (CA) is a major clinical challenge. EEG is frequently used for neuroprognostication in adults, but has not been sufficiently validated for this indication in children. Using machine learning techniques, we studied the predictive value of quantitative EEG (qEEG) features for survival 12 months after CA, based on EEG recordings obtained 24 hours after CA in children. The results were confirmed through visual analysis of EEG background patterns.

METHODS

This is a retrospective single-center study including children (0-17 years) with CA, who were subsequently admitted to the pediatric intensive care unit (PICU) of a tertiary care hospital between 2012 and 2021 after return of circulation (ROC) and were monitored using EEG at 24 hours after ROC. Signal features were extracted from a 30-minute EEG segment 24 hours after CA and used to train a random forest model. The background pattern from the same EEG fragment was visually classified. The primary outcome was survival or death 12 months after CA. Analysis of the prognostic accuracy of the model included calculation of receiver-operating characteristic and predictive values. Feature contribution to the model was analyzed using Shapley values.

RESULTS

Eighty-six children were included (in-hospital CA 27%, out-of-hospital CA 73%). The median age at CA was 2.6 years; 53 (62%) were male. Mortality at 12 months was 56%; main causes of death on the PICU were withdrawal of life-sustaining therapies because of poor neurologic prognosis (52%) and brain death (31%). The random forest model was able to predict death at 12 months with an accuracy of 0.77 and positive predictive value of 1.0. Continuity and amplitude of the EEG signal were the signal parameters most contributing to the model classification. Visual analysis showed that no patients with a background pattern other than continuous with amplitudes exceeding 20 μV were alive after 12 months.

DISCUSSION

Both qEEG and visual EEG background classification for registrations obtained 24 hours after ROC form a strong predictor of nonsurvival 12 months after CA in children.

Reducing Chest Compression Pauses During Pediatric ECPR

Objective: To quantify chest compression (CC) pauses during pediatric ECPR (CPR incorporating ECMO) and implement sustainable quality improvement (QI) initiatives to reduce CC pauses during ECMO cannulation. Methods: We retrospectively identified baseline CC pause characteristics during pediatric ECPR events (pre-intervention), deployed QI interventions to reduce CC pause length, and then prospectively quantified CC pause metrics post-QI interventions (post-intervention). Data were gathered from a single center review of CC-pause characteristics in children less than 18 years old with a PICU ECPR arrest. QI Interventions included: (1) sharing baseline CC data with ECPR stakeholders, (2) establishing consensus among providers regarding areas for improvement, and (3) creating a communication aid to encourage counting CC pauses out loud. Multidisciplinary ECPR simulations allowed for practice of these skills. Using telemetry data, CC pause metrics were analyzed in the medical (CPR before cannulation) and surgical (CPR during ECMO cannulation, demarcated by the sterile draping of the patient) phases of ECPR, pre- and post-intervention. Results: Pre-intervention, 11 ECPR events (5 central cannulation, 6 peripheral cannulation) met inclusion criteria compared with 14 ECPR events (2 central, 12 peripheral) post-intervention. Pre-intervention analysis identified longer CC pauses and lower chest compression fraction (CCF) during the surgical versus medical phase of ECPR. Compared to pre-intervention data, CCF during the surgical phase of ECPR improved from 66% to 81% (73-85%) post-intervention (P = .02). Median CC pause length was significantly reduced from 20 s pre-intervention to 10.5 (9-13) seconds post-intervention (P = .01). There was no change in the surgical phase of ECPR duration (44 min pre- vs 41 min post-intervention, P = .8) or survival to hospital discharge (45% vs 21%, P = .4). Conclusion: Simple and feasible communication interventions during ECPR can minimize CC pauses, increase CCF and improve CPR quality without prolonging the time needed for ECMO cannulation.

Association of cumulative oxygen and carbon dioxide levels with neurologic outcome after pediatric cardiac arrest resuscitation: A multicenter cohort study

Objective

We aimed to (1) determine the association between cumulative PaO2 and PaCO2 exposure 24 h post-return of circulation and survival with favorable neurologic outcome. And (2) to assess adherence to American Heart Association post-cardiac arrest care treatment goals (PaO2 75-100 mmHg and PaCO2 35-45 mmHg).

Design and setting

Prospectively collected data were analysed from five Pediatric Resuscitation Quality collaborative sites supplemented with retrospective PaO2 and PaCO2 data.

Patients

Children aged 1 day-17 years with return of circulation after cardiac arrest, admitted 2019-2022, with ≥ 4 arterial blood gasses spanning at least 12 h within 24 h post-return of ciculation, were eligible. Congenital cyanotic heart disease events were excluded.

Measurements

Area under the curve calculation provided hourly cumulative PaO2 and PaCO2 exposures per child and similarly guideline recommended cumulative ranges. The primary outcome was survival to hospital discharge with favorable neurologic outcome defined as a Pediatric Cerebral Performance Category 1-3, or no pre-arrest baseline difference.

Main results

Among 292 included children (median age 2.6 years (IQR 0.4-10.9)), 57 % survived to discharge and 48 % had favorable neurologic outcome (88 % of survivors). Cumulative PaO2 and PaCO2 exposure 0-24 h post-return of circulation were not significantly associated with favorable neurologic outcome in multivariable analysis (OR 1.0, 95 %CI 0.98-1.02 and OR 0.97, 95 %CI 0.87-1.09 respectively). Cumulative PaO2 and PaCO2 remained within guideline recommended ranges for 24 % and 58 % of children respectively with median areas under the curve over 0 - 24 h of 2664 mmHg (2151 - 3249 mmHg) for PaO2 and 948 mmHg (853 - 1051 mmHg) for PaCO2. AHA post-cardiac arrest care guideline recommendations for PaO2 (1800-2400 mmHg) and PaCO2 (840-1080 mmHg) were recalculated as area under the curve ranges. Achieving both normoxia and normocapnia was observed in 12 % of children.

Conclusions

Cumulative PaO2 and PaCO2 exposure in the first 24 h post-return of circulation was not associated with survival with favorable neurologic outcome. Pediatric AHA post-cardiac arrest care guideline normoxia and normocapnia goals were often not met. Larger cohort studies are necessary to improve the accuracy of cumulative exposure calculations, assess the long-term effects of PaO2 and PaCO2 exposure, and explore the influence of other post-cardiac arrest care therapeutic strategies.

Long-term outcomes of patients who received extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest: Analysis of EXCEL registry data

Objective

To describe the six-month functional outcomes of patients who received extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest (IHCA) in Australia.

Design

Secondary analysis of EXCEL registry data.

Setting

EXCEL is a high-quality, prospective, binational registry including adult patients who receive extracorporeal membrane oxygenation (ECMO) in Australia and New Zealand.

Participants

Patients reported to the EXCEL registry who received ECPR following IHCA and had the six-month outcome data available were included.

Main outcome measures

The primary outcome was functional outcome at six months measured using the modified Rankin scale (mRS). The secondary outcomes included mortality, disability, health status, and complications.

Results

Between 15th February 2019 and 31st August 2022, 113/1251 (9.0%) patients in the registry received ECPR following IHCA (mean age 50.7 ± 13.7 years; 79/113 (69.9%) male; 74/113 (65.5%) non-shockable rhythm). At 6 months, 37/113 (32.7%) patients were alive, most (27/34 [79.4%]) with a good functional outcome (mRS 0-3). Patients had increased disability [WHODAS % Score 25.58 ± 23.39% vs 6.45 ± 12.32%; mean difference (MD) [95% (confidence interval) CI] -19.13 (-28.49 to -9.77); p < 0.001] and worse health status [EuroQol five-dimension, five-level (EQ-5D-5L) index value 0.73 ± 0.23 vs. 0.89 ± 0.14; MD (95% CI) 0.17 (0.07 to 0.26); p = 0.003] at six months compared with the baseline. The patients reported a median of 4.5 (2-6) complications at six-month follow-up.

Conclusion

One in three patients who received ECPR following IHCA were alive at six months and most had a good functional outcome. However, survivors reported higher levels of disability and a worse health status at six months compared with the baseline and ongoing complications were common.

Why physicians use sodium bicarbonate during cardiac arrest: A cross-sectional survey study of adult and pediatric clinicians

Background

Despite recommendations against routine use, sodium bicarbonate (SB) is administered in approximately 50% of adult and pediatric in-hospital cardiac arrest (IHCA).

Methods

Cross-sectional electronic survey of adult and pediatric attending physicians at two academic hospitals in Boston, Massachusetts. The survey included two IHCA vignettes. Additional open- and closed-ended items explored clinician beliefs surrounding intra-arrest SB and perspectives on a hypothetical clinical trial comparing SB with placebo.

Results

Of the 356 physicians invited, 224 (63 %) responded. Of these, 54 (24 %) said they would "probably" or "definitely give" SB in Scenario 1 (10-minute asystolic arrest) compared to 110 (49 %) for Scenario 2 (20-minute asystolic arrest; p < 0.001). The most frequently reported indications for SB were: hyperkalemia (78 %); metabolic acidosis (76 %); tricyclic anti-depressant overdose (71 %); and prolonged arrest duration (64 %). Of the 207 (92 %) respondents who reported using intra-arrest SB in at least some circumstances, the most common reasons for use were: "last ditch effort" in a prolonged arrest (75 %) and belief that there were physiologic benefits (63 %). When asked of the importance of a clinical trial to guide intra-arrest SB use, 188 (84 %) respondents felt it was at least of average importance, and 140 (63 %) said they would be "somewhat" or "very comfortable" enrolling patients in a trial comparing SB and placebo in IHCA.

Conclusions

Physicians reported practice variations surrounding cardiac arrest management with SB. Respondents commonly cited metabolic acidosis and prolonged arrest duration as indications for intra-arrest SB, despite not being supported by the American Heart Association's advanced life support guidelines.

Deep learning-based Emergency Department In-hospital Cardiac Arrest Score (Deep EDICAS) for early prediction of cardiac arrest and cardiopulmonary resuscitation in the emergency department

BACKGROUND

Timely identification of deteriorating patients is crucial to prevent the progression to cardiac arrest. However, current methods predicting emergency department cardiac arrest are primarily static, rule-based with limited precision and cannot accommodate time-series data. Deep learning has the potential to continuously update data and provide more precise predictions throughout the emergency department stay.

METHODS

We developed and internally validated a deep learning-based scoring system, the Deep EDICAS for early prediction of cardiac arrest and a subset of arrest, cardiopulmonary resuscitation (CPR), in the emergency department. Our proposed model effectively integrates tabular and time series data to enhance predictive accuracy. To address data imbalance and bolster early prediction capabilities, we implemented data augmentation techniques.

RESULTS

Our system achieved an AUPRC of 0.5178 and an AUROC of 0.9388 on on data from the National Taiwan University Hospital. For early prediction, our system achieved an AUPRC of 0.2798 and an AUROC of 0.9046, demonstrating superiority over other early warning scores. Moerover, Deep EDICAS offers interpretability through feature importance analysis.

CONCLUSION

Our study demonstrates the effectiveness of deep learning in predicting cardiac arrest in emergency department. Despite the higher clinical value associated with detecting patients requiring CPR, there is a scarcity of literature utilizing deep learning in CPR detection tasks. Therefore, this study embarks on an initial exploration into the task of CPR detection.

Aetiology and predictors of outcome in non-shockable in-hospital cardiac arrest: A retrospective cohort study from the Swedish Registry for Cardiopulmonary Resuscitation

BACKGROUND

Non-shockable in-hospital cardiac arrest (IHCA) is a condition with diverse aetiology, predictive factors, and outcome. This study aimed to compare IHCA with initial asystole or pulseless electrical activity (PEA), focusing specifically on their aetiologies and the significance of predictive factors.

METHODS

Using the Swedish Registry of Cardiopulmonary Resuscitation, adult non-shockable IHCA cases from 2018 to 2022 (n = 5788) were analysed. Exposure was initial rhythm, while survival to hospital discharge was the primary outcome. A random forest model with 28 variables was used to generate permutation-based variable importance for outcome prediction.

RESULTS

Overall, 60% of patients (n = 3486) were male and the median age was 75 years (IQR 67-81). The most frequent arrest location (46%) was on general wards. Comorbidities were present in 79% of cases and the most prevalent comorbidity was heart failure (33%). Initial rhythm was PEA in 47% (n = 2702) of patients, and asystole in 53% (n = 3086). The most frequent aetiologies in both PEA and asystole were cardiac ischemia (24% vs. 19%, absolute difference [AD]: 5.4%; 95% confidence interval [CI] 3.0% to 7.7%), and respiratory failure (14% vs. 13%, no significant difference). Survival was higher in asystole (24%) than in PEA (17%) (AD: 7.3%; 95% CI 5.2% to 9.4%). Cardiopulmonary resuscitation (CPR) durations were longer in PEA, 18 vs 15 min (AD 4.9 min, 95% CI 4.0-5.9 min). The duration of CPR was the single most important predictor of survival across all subgroup and sensitivity analyses. Aetiology ranked as the second most important predictor in most analyses, except in the asystole subgroup where responsiveness at cardiac arrest team arrival took precedence.

CONCLUSIONS

In this nationwide registry study of non-shockable IHCA comparing asystole to PEA, cardiac ischemia and respiratory failure were the predominant aetiologies. Duration of CPR was the most important predictor of survival, followed by aetiology. Asystole was associated with higher survival compared to PEA, possibly due to shorter CPR durations and a larger proportion of reversible aetiologies.

Pediatric In-Hospital Cardiac Arrest: An Examination of Resuscitation Outcomes

Background and Objectives: We aimed to assess the outcomes of pediatric in-hospital cardiac arrests (IHCAs) and to identify key factors influencing survival. Materials and Methods: This retrospective, single-center study examined the demographic characteristics, symptoms, comorbidities, initial rhythm, duration of cardiopulmonary resuscitation (CPR), lactate levels, and outcomes of pediatric patients with IHCAs and compared these parameters between survivors and non-survivors. Results: A total of 43 patients were included in this study, including 21 boys (48.8%) and 22 girls (51.2%) with a median age of 36 months (range 1-203). CPR was initiated due to pulselessness in 23 patients (53.5%), respiratory arrest in 13 (30.2%), and bradycardia in 7 (16.3%). The first monitored rhythm in the emergency department was asystole in 29 patients (67.4%) and bradycardia in 14 (32.6%). Despite effective CPR, the mortality rate was 65.1% (n = 28). As a prognostic factor, asystole was found to be more common in non-survivors than in survivors (83.1% vs. 40%, p = 0.005). Additionally, lactate levels (16.6 vs. 10.6, p = 0.04) and CPR duration (45 vs. 15 min, p < 0.001) were significantly higher in non-survivors. Conclusions: IHCAs remain a critical concern, with varying outcomes influenced by factors such as initial rhythm, lactate levels, and CPR duration.

Leadership factors for cardiopulmonary resuscitation for clinicians in-hospital; behaviours, skills and strategies: A systematic review and synthesis without meta-analysis

AIM

To identify leadership factors for clinicians during in-hospital cardiopulmonary resuscitation.

DESIGN

Systematic review with synthesis without meta-analysis.

METHODS

The review was guided by SWiM, assessed for quality using CASP and reported with PRISMA.

DATA SOURCES

Cochrane, EMBASE, PubMed, Medline, Scopus and CINAHL (years of 2013-2023) and a manual reference list search of all included studies.

RESULTS

A total of 60 papers were identified with three major themes of useful resuscitation leadership; 'social skills', 'cognitive skills and behaviour' and 'leadership development skills' were identified. Main factors included delegating effectively, while being situationally aware of team members' ability and progress during resuscitation, and being empathetic and supportive, yet 'controlling the room' using a hands-off style. Shared decision-making to reduce cognitive load for one leader was shown to improve effective teamwork. Findings were limited by heterogeneity of studies and inconsistently applied tools to measure leadership.

CONCLUSION

Traditional authoritarian leadership styles are not wanted by team members with preference for shared leadership and collaboration. Balancing this with the need for team members to see leaders in 'control of the room' brings new challenges for leaders and trainers of resuscitation.

IMPLICATIONS FOR NURSING PROFESSION

All clinicians need effective leadership skills for cardiopulmonary resuscitation in-hospital. Nurses provide first response and ongoing leadership for cardiopulmonary resuscitation. Nurses typically display suitable skills that align with useful resuscitation leader factors.

IMPACT

What were the main findings? Collaboration rather than an authoritarian approach to leadership is preferred by team members. Nurses are suitable to 'control the room'. Restricting resuscitation team size will manage disruptive behaviour of team members.

TRIAL REGISTRATION

PROSPERO Registration: CRD42022385630.

PATIENT OF PUBLIC CONTRIBUTION

No patient of public contribution.

Evaluating the current breadth of randomized control trials on cardiac arrest: A scoping review

Objectives

Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022.

Methods

We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non-traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually.

Results

We identified 1764 unique publications, 87 RCTs were included after title/abstract and full-text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n = 13, 15%) and the United States (n = 9, 10%) conducted the majority of trials. Nearly all trials included adults (n = 84, 97%) and few included children (n = 9, 10%). The majority of trials focused on out-of-hospital cardiac arrest (n = 62, 71%). Thirty-eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra-arrest (53%) and post-arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days.

Conclusions

Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in-hospital cardiac arrest and pediatric patients.

In-hospital cardiac arrest characteristics, causes and outcomes in patients with cardiovascular disease across different departments: a retrospective study

BACKGROUND

Cardiac etiologies arrest accounts for almost half of all in-hospital cardiac arrest (IHCA), and previous studies have shown that the location of IHCA is an important factor affecting patient outcomes. The aim was to compare the characteristics, causes and outcomes of cardiovascular disease in patients suffering IHCA from different departments of Fuwai hospital in Beijing, China.

METHODS

We included patients who were resuscitated after IHCA at Fuwai hospital between March 2017 and August 2022. We categorized the departments where cardiac arrest occurred as cardiac surgical or non-surgical units. Independent predictors of in-hospital survival were assessed by logistic regression.

RESULTS

A total of 119 patients with IHCA were analysed, 58 (48.7%) patients with cardiac arrest were in non-surgical units, and 61 (51.3%) were in cardiac surgical units. In non-surgical units, acute myocardial infarction/cardiogenic shock (48.3%) was the main cause of IHCA. Cardiac arrest in cardiac surgical units occurred mainly in patients who were planning or had undergone complex aortic replacement (32.8%). Shockable rhythms (ventricular fibrillation/ventricular tachycardia) were observed in approximately one-third of all initial rhythms in both units. Patients who suffered cardiac arrest in cardiac surgical units were more likely to return to spontaneous circulation (59.0% vs. 24.1%) and survive to hospital discharge (40.0% vs. 10.2%). On multivariable regression analysis, IHCA in cardiac surgical units (OR 5.39, 95% CI 1.90-15.26) and a shorter duration of resuscitation efforts (≤ 30 min) (OR 6.76, 95% CI 2.27-20.09) were associated with greater survival rate at discharge.

CONCLUSION

IHCA occurring in cardiac surgical units and a duration of resuscitation efforts less than 30 min were associated with potentially increased rates of survival to discharge.

The Discover In-Hospital Cardiac Arrest (Discover IHCA) Study: An Investigation of Hospital Practices After In-Hospital Cardiac Arrest

IMPORTANCE

In-hospital cardiac arrest (IHCA) is a significant public health burden. Rates of return of spontaneous circulation (ROSC) have been improving, but the best way to care for patients after the initial resuscitation remains poorly understood, and improvements in survival to discharge are stagnant. Existing North American cardiac arrest databases lack comprehensive data on the post-resuscitation period, and we do not know current post-IHCA practice patterns. To address this gap, we developed the Discover In-Hospital Cardiac Arrest (Discover IHCA) study, which will thoroughly evaluate current post-IHCA care practices across a diverse cohort.

OBJECTIVES

Our study collects granular data on post-IHCA treatment practices, focusing on temperature control and prognostication, with the objective of describing variation in current post-IHCA practice.

DESIGN, SETTING, AND PARTICIPANTS

This is a multicenter, prospectively collected, observational cohort study of patients who have suffered IHCA and have been successfully resuscitated (achieved ROSC). There are 24 enrolling hospital systems (23 in the United States) with 69 individual enrolling hospitals (39 in the United States). We developed a standardized data dictionary, and data collection began in October 2023, with a projected 1000 total enrollments. Discover IHCA is endorsed by the Society of Critical Care Medicine.

INTERVENTIONS, OUTCOMES, AND ANALYSIS

The study collects data on patient characteristics including pre-arrest frailty, arrest characteristics, and detailed information on post-arrest practices and outcomes. Data collection on post-IHCA practice was structured around current American Heart Association and European Resuscitation Council guidelines. Among other data elements, the study captures post-arrest temperature control interventions and post-arrest prognostication methods. Analysis will evaluate variations in practice and their association with mortality and neurologic function.

CONCLUSIONS

We expect this study, Discover IHCA, to identify variability in practice and outcomes following IHCA, and be a vital resource for future investigations into best-practice for managing patients after IHCA.

Mild (34 °C) versus moderate hypothermia (24 °C) in a swine model of extracorporeal cardiopulmonary resuscitation

Background

The role of hypothermia in post-arrest neuroprotection is controversial. Animal studies suggest potential benefits with lower temperatures, but high-fidelity ECPR models evaluating temperatures below 30 °C are lacking.

Objectives

To determine whether rapid cooling to 24 °C initiated upon reperfusion reduces brain injury compared to 34 °C in a swine model of ECPR.

Methods

Twenty-four female pigs had electrically induced VF and mechanical CPR for 30 min. Animals were cannulated for VA-ECMO and cooled to either 34 °C for 4 h (n = 8), 24 °C for 1 h with rewarming to 34 °C over 3 h (n = 7), or 24 °C for 4 h without rewarming (n = 9). Cooling was initiated upon VA-ECMO reperfusion by circulating ice water through the oxygenator. Brain temperature and cerebral and systemic hemodynamics were continuously monitored. After four hours on VA-ECMO, brain tissue was obtained for examination.

Results

Target brain temperature was achieved within 30 min of reperfusion (p = 0.74). Carotid blood flow was higher in the 24 °C without rewarming group throughout the VA-ECMO period compared to 34 °C and 24 °C with rewarming (p < 0.001). Vasopressin requirement was higher in animals treated with 24 °C without rewarming (p = 0.07). Compared to 34 °C, animals treated with 24 °C with rewarming were less coagulopathic and had less immunohistochemistry-detected neurologic injury. There were no differences in global brain injury score.

Conclusions

Despite improvement in carotid blood flow and immunohistochemistry detected neurologic injury, reperfusion at 24 °C with or without rewarming did not reduce early global brain injury compared to 34 °C in a swine model of ECPR.

Association of Postarrest Hypotension Burden With Unfavorable Neurologic Outcome After Pediatric Cardiac Arrest

OBJECTIVE

Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest.

DESIGN

Retrospective observational study.

SETTING

Academic PICU.

PATIENTS

Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arrest who had invasive ABP monitoring during postcardiac arrest care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

High-resolution continuous ABP was analyzed up to 24 hours after the return of circulation (ROC). Hypotension burden was the time-normalized integral area between mean arterial pressure (MAP) and fifth percentile MAP for age. The primary outcome was unfavorable neurologic status (pediatric cerebral performance category ≥ 3 with change from baseline) at hospital discharge. Mann-Whitney U tests compared hypotension burden, duration, and magnitude between favorable and unfavorable patients. Multivariable logistic regression determined the association of unfavorable outcomes with hypotension burden, duration, and magnitude at various percentile thresholds from the 5th through 50th percentile for age. Of 140 patients (median age 53 [interquartile range 11-146] mo, 61% male); 63% had unfavorable outcomes. Monitoring duration was 21 (7-24) hours. Using a MAP threshold at the fifth percentile for age, the median hypotension burden was 0.01 (0-0.11) mm Hg-hours per hour, greater for patients with unfavorable compared with favorable outcomes (0 [0-0.02] vs. 0.02 [0-0.27] mm Hg-hr per hour, p < 0.001). Hypotension duration and magnitude were greater for unfavorable compared with favorable patients (0.03 [0-0.77] vs. 0.71 [0-5.01]%, p = 0.003; and 0.16 [0-1.99] vs. 2 [0-4.02] mm Hg, p = 0.001). On logistic regression, a 1-point increase in hypotension burden below the fifth percentile for age (equivalent to 1 mm Hg-hr of burden per hour of recording) was associated with increased odds of unfavorable outcome (adjusted odds ratio [aOR] 14.8; 95% CI, 1.1-200; p = 0.040). At MAP thresholds of 10th-50th percentiles for age, MAP burden below the threshold was greater in unfavorable compared with favorable patients in a dose-dependent manner.

CONCLUSIONS

High-resolution continuous ABP data can be used to quantify hypotension burden after pediatric cardiac arrest. The burden, duration, and magnitude of hypotension are associated with unfavorable neurologic outcomes.

Correlation between hospital rates of survival to discharge and long-term survival for in-hospital cardiac arrest: Insights from Get With The Guidelines®-Resuscitation registry

AIM

Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival.

METHODS

We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients.

RESULTS

Among 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7-20.4%), 14.9% (13.2-16.7%), 10.3% (9.1-12.1%), and 7.6% (6.8-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively.

CONCLUSIONS

There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.

Targeted Temperature Management for Out-of-Hospital Cardiac Arrest Survivors

Targeted temperature management (TTM), specifically therapeutic hypothermia, has been proposed to provide neuroprotective and mortality benefits for out-of-hospital cardiac arrest (OHCA) survivors. This proposition was based on small-scale trials from the early 2000s, leading to its incorporation into various international guidelines. The proposed neuroprotective mechanisms include reducing cerebral metabolic rate, stabilizing the blood-brain barrier, reducing the release of excitatory neurotransmitters, and suppressing apoptotic pathways. However, these early trials have been criticized for their high risk of bias and lack of standardized protocols. Recent evidence from more rigorously controlled randomized trials indicates no significant association between hypothermia and improved neurological outcomes or survival rates. This review explores the latest clinical evidence on TTM for OHCA patients, discussing the pathophysiology, evaluating the effectiveness of hypothermia through various clinical trials, and providing recommendations for future research and clinical practice.

Long-term survival comparison of patients admitted to the intensive care unit following in-hospital cardiac arrest in perioperative and ward settings. A multicentre retrospective cohort study

PURPOSE

Perioperative in-hospital cardiac arrests (Perioperative IHCAs) may have better outcomes than IHCAs in the ward (Ward IHCAs), due to enhanced monitoring and faster response. However, quantitative comparisons of their long-term outcomes are lacking, posing challenges for prognostication.

METHODS

This retrospective multicentre study included adult intensive care unit (ICU) admissions from theatre/recovery or wards with a diagnosis of cardiac arrest between January 2018 and March 2022. We used data from 175 ICUs in the ANZICS adult patient database. The primary outcome was a survival time of up to 4 years. We used the Cox proportional hazards model adjusted for Sequential Organ Failure Assessment (SOFA) score, age, sex, comorbidities, hospital type, treatment limitation on admission to the ICU, and ICU treatments. Subgroup analyses examined age (≥ 65 years), intubation within the first 24 h, elective vs. emergency admission, and survival on discharge.

RESULTS

Of 702,675 ICU admissions, 5,659 IHCAs were included (Perioperative IHCA 38%; Ward IHCA 62%). Perioperative IHCA group were younger, less frail, and less comorbid. Perioperative IHCA were most frequent in patients admitted to ICU after cardiovascular, gastrointestinal, or trauma surgeries. Perioperative IHCA group had longer 4-year survival (59.9% vs. 33.0%, p < 0.001) than the Ward IHCA group, even after adjustments (adjusted hazard ratio [HR]: 0.63, 95% confidence interval [CI] 0.57-0.69). This was concordant across all subgroups. Of note, older patients with Perioperative IHCA survived longer than both younger and older patients with Ward IHCA.

CONCLUSION

Patients admitted to the ICU following Perioperative IHCA had longer survival than Ward IHCA. Future studies on IHCA should distinguish these patients.

Epinephrine Dosing Intervals Are Associated With Pediatric In-Hospital Cardiac Arrest Outcomes: A Multicenter Study

OBJECTIVES

Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared with greater than or equal to 3 minutes.

DESIGN

This study is a secondary analysis of The ICU-RESUScitation Project (NCT028374497), a multicenter trial of a quality improvement bundle of physiology-directed CPR training and post-cardiac arrest debriefing.

SETTING

Eighteen PICUs and pediatric cardiac ICUs in the United States.

PATIENTS

Subjects were 18 years young or younger and 37 weeks old or older corrected gestational age who had an index cardiac arrest. Patients who received less than two doses of epinephrine, received extracorporeal CPR, or had dosing intervals greater than 8 minutes were excluded.

INTERVENTIONS

The primary exposure was an epinephrine dosing interval of less than 3 vs. greater than or equal to 3 minutes.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was survival to discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1-2 or no change from baseline. Regression models evaluated the association between dosing intervals and: 1) survival outcomes and 2) CPR duration. Among 382 patients meeting inclusion and exclusion criteria, median age was 0.9 years (interquartile range 0.3-7.6 yr) and 45% were female. After adjustment for confounders, dosing intervals less than 3 minutes were not associated with survival with favorable neurologic outcome (adjusted relative risk [aRR], 1.10; 95% CI, 0.84-1.46; p = 0.48) but were associated with improved sustained return of spontaneous circulation (ROSC) (aRR, 1.21; 95% CI, 1.07-1.37; p < 0.01) and shorter CPR duration (adjusted effect estimate, -9.5 min; 95% CI, -14.4 to -4.84 min; p < 0.01).

CONCLUSIONS

In patients receiving at least two doses of epinephrine, dosing intervals less than 3 minutes were not associated with neurologic outcome but were associated with sustained ROSC and shorter CPR duration.

Responding to In-hospital Cardiac Arrests During Times of System-wide Strain: A Code Refresher Training

BACKGROUND

Pandemic conditions of system-wide strain are associated with increased rates of in-hospital cardiac arrest (IHCA). During normal times, medical-surgical nurses may forget cardiopulmonary resuscitation (CPR) skills as soon as 3 months after training, leaving them unprepared and anxious about managing cardiac arrests. During pandemic surges, heightened anxiety can also impact concentration and confidence.

METHOD

Clinicians offered a 45-minute mock code training refresher for medical-surgical nurses to improve confidence performing CPR while adhering to pandemic-related safety procedures. In this pre-post clinical education project, nurses' confidence was measured with the Nursing Anxiety and Self-Confidence with Clinical Decision Making© Scale.

RESULTS

Although the results were not statistically significant, participants verbally reported increased confidence to initiate resuscitation, collaborate with team members, and use personal protective equipment during the posttraining debrief.

CONCLUSION

A high percentage of RNs do not have adequate confidence and/or competence in performing CPR, particularly during times of system-wide strain, and this brief, inexpensive refresher training warrants further study. [J Contin Educ Nurs. 2024;55(9):442-448.].

Elevated serum neurologic biomarker profiles after cardiac arrest in a porcine model

Introduction

Swine exhibit cerebral cortex mitochondrial dysfunction and neuropathologic injury after hypoxic cardiac arrest treated with hemodynamic-directed CPR (HD-CPR) despite normal Cerebral Performance Category scores. We analyzed the temporal evolution of plasma protein biomarkers of brain injury and inflammatory cytokines, as well as cerebral cortical mitochondrial injury and neuropathology for five days following pediatric asphyxia-associated cardiac arrest treated with HD-CPR.

Methods

One-month-old swine underwent asphyxia associated cardiac arrest, 10-20 min of HD-CPR (goal SBP 90 mmHg, coronary perfusion pressure 20 mmHg), and randomization to post-ROSC survival duration (24, 48, 72, 96, 120 h; n = 3 per group) with standardized post-resuscitation care. Plasma neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), and cytokine levels were collected pre-injury and 1, 6, 24, 48, 72, 96, and 120 h post-ROSC. Cerebral cortical tissue was assessed for: mitochondrial respirometry, mass, and dynamic proteins; oxidative injury; and neuropathology.

Results

Relative to pre-arrest baseline (9.4 pg/ml [6.7-12.6]), plasma NfL was increased at all post-ROSC time points. Each sequential NfL measurement through 48 h was greater than the previous value {1 h (12.7 pg/ml [8.4-14.6], p = 0.01), 6 h (30.9 pg/ml [17.7-44.0], p = 0.0004), 24 h (59.4 pg/ml [50.8-96.1], p = 0.0003) and 48 h (85.7 pg/ml [61.9-118.7], p = 0.046)}. Plasma GFAP, inflammatory cytokines or cerebral cortical tissue measurements were not demonstrably different between time points.

Conclusions

In a swine model of pediatric cardiac arrest, plasma NfL had an upward trajectory until 48 h post-ROSC after which it remained elevated through five days, suggesting it may be a sensitive marker of neurologic injury following pediatric cardiac arrest.

Rapid cycle deliberate practice versus postsimulation debriefing in pediatric cardiopulmonary resuscitation training: a randomized controlled study

OBJECTIVE

Simulation plays an important role in cardiopulmonary resuscitation training. Comparing postsimulation debriefing with rapid cycle deliberate practice could help determine the best simulation strategy for pediatric cardiopulmonary resuscitation training among pediatric residents.

METHODS

This is a single-blind, prospective, randomized controlled study. First- and second year pediatric residents were enrolled and randomized into two groups (1:1 ratio): rapid cycle deliberate practice group (intervention) or postsimulation debriefing group (control). They participated in two rounds of simulated pediatric cardiopulmonary arrest to assess the simulated pediatric cardiopulmonary resuscitation performance gain (round 1) and retention after a 5-6 week washout period (round 2). Scenarios were video-recorded and analyzed by blinded evaluators. The main outcome was the time to initiation of chest compressions. Secondary outcomes included time to recognize a cardiopulmonary arrest, time to recognize a shockable rhythm, time to defibrillation, time to initiation of chest compressions after defibrillation, and chest compression fraction.

RESULTS

Sixteen groups participated in the first round and fifteen groups in the second one. Time to intiation of chest compressions decreased from preintervention scenario to the round 1 testing scenario and increased from round 1 to round 2 testing scenario. However, no interaction effects nor group effects were observed (p=0.885 and p=0.329, respectively). There were no significant differences between the two groups regarding the secondary outcomes.

CONCLUSION

Despite an overall improvement in simulated pediatric cardiopulmonary resuscitation performance, we did not observe significant differences between the two groups regarding the analyzed variables. The decline in simulated pediatric cardiopulmonary resuscitation performance after 5 weeks suggests the need for shorter time intervals between training sessions.

In-hospital cardiac arrest after STEMI: prevention strategies and post-arrest care

INTRODUCTION

In-Hospital Cardiac Arrest (IHCA) after ST-segment Elevation Myocardial Infarction (STEMI) is a subset of IHCA with high morbidity. While information on this selected group of patients is limited, closer inspection reveals that this is a challenging patient population with certain risk factors for IHCA following treatment of STEMI.

AREAS COVERED

In this review article, strategies for prevention of IHCA post STEMI are reviewed, as well as best-practices for the care of STEMI patients post-IHCA.

EXPERT OPINION

Early and successful reperfusion is key for the prevention of IHCA and has a significant impact on in-hospital mortality. A number of pharmacological treatments have also been studied that can impact the progression to IHCA. Development of cardiogenic shock post-STEMI increases mortality and raises the risk of cardiac arrest. The treatment of IHCA follows the ACLS algorithm with some notable exceptions.

Prediction of In-Hospital Cardiac Arrest in the Intensive Care Unit: Machine Learning-Based Multimodal Approach

Background

Early identification of impending in-hospital cardiac arrest (IHCA) improves clinical outcomes but remains elusive for practicing clinicians.

Objective

We aimed to develop a multimodal machine learning algorithm based on ensemble techniques to predict the occurrence of IHCA.

Methods

Our model was developed by the Multiparameter Intelligent Monitoring of Intensive Care (MIMIC)-IV database and validated in the Electronic Intensive Care Unit Collaborative Research Database (eICU-CRD). Baseline features consisting of patient demographics, presenting illness, and comorbidities were collected to train a random forest model. Next, vital signs were extracted to train a long short-term memory model. A support vector machine algorithm then stacked the results to form the final prediction model.

Results

Of 23,909 patients in the MIMIC-IV database and 10,049 patients in the eICU-CRD database, 452 and 85 patients, respectively, had IHCA. At 13 hours in advance of an IHCA event, our algorithm had already demonstrated an area under the receiver operating characteristic curve of 0.85 (95% CI 0.815-0.885) in the MIMIC-IV database. External validation with the eICU-CRD and National Taiwan University Hospital databases also presented satisfactory results, showing area under the receiver operating characteristic curve values of 0.81 (95% CI 0.763-0.851) and 0.945 (95% CI 0.934-0.956), respectively.

Conclusions

Using only vital signs and information available in the electronic medical record, our model demonstrates it is possible to detect a trajectory of clinical deterioration up to 13 hours in advance. This predictive tool, which has undergone external validation, could forewarn and help clinicians identify patients in need of assessment to improve their overall prognosis.

Characteristics of Pediatric In-Hospital Cardiac Arrests and Resuscitation Duration

Importance

Cardiopulmonary resuscitation (CPR) duration is associated with cardiac arrest survival.

Objectives

To describe characteristics associated with CPR duration among hospitalized children without return of circulation (ROC) (patient-level analysis) and determine whether hospital median CPR duration in patients without ROC is associated with survival (hospital-level analysis).

Design, Setting, and Participants

This retrospective cohort study of patients undergoing pediatric in-hospital CPR between January 1, 2000, and December 31, 2021, used data from the Get With the Guidelines-Resuscitation registry. Children receiving chest compressions for at least 2 minutes and/or defibrillation were included in the patient-level analysis. For the hospital-level analysis, sites with at least 20 total events and at least 5 events without ROC were included. Data were analyzed from December 1, 2022, to November 15, 2023.

Exposures

For the patient-level analysis, the exposure was CPR duration in patients without ROC. For the hospital-level analysis, the exposure was quartile of median CPR duration in events without ROC at each hospital.

Main Outcomes and Measures

For the patient-level analysis, outcomes were patient and event factors, including race and ethnicity and event location; we used a multivariable hierarchical linear regression model to assess factors associated with CPR duration in patients without ROC. For the hospital-level analysis, the main outcome was survival to discharge among all site events; we used a random intercept multivariable hierarchical logistic regression model to examine the association between hospital quartile of CPR duration and survival to discharge.

Results

Of 13 899 events, 3859 patients did not have ROC (median age, 7 months [IQR, 0 months to 7 years]; 2175 boys [56%]). Among event nonsurvivors, median CPR duration was longer in those with initial rhythms of bradycardia with poor perfusion (8.37 [95% CI, 5.70-11.03] minutes; P < .001), pulseless electrical activity (8.22 [95% CI, 5.44-11.00] minutes; P < .001), and pulseless ventricular tachycardia (6.17 [95% CI, 0.09-12.26] minutes; P = .047) (vs asystole). Shorter median CPR duration was associated with neonates compared with older children (-4.86 [95% CI, -8.88 to -0.84] minutes; P = .02), emergency department compared with pediatric intensive car7 e unit location (-4.02 [95% CI, -7.48 to -0.57] minutes; P = .02), and members of racial or ethnic minority groups compared with White patients (-3.67 [95% CI, -6.18 to -1.17]; P = .004). Among all CPR events, the adjusted odds of survival to discharge differed based on hospital quartile of median CPR duration among events without ROC; compared with quartile 1 (15.0-25.9 minutes), the adjusted odds ratio for quartile 2 (26.0-29.4 minutes) was 1.22 (95% CI, 1.09-1.36; P < .001); for quartile 3 (29.5-32.9 minutes), 1.23 (95% CI, 1.08-1.39; P = .002); and for quartile 4 (33.0-53.0 minutes), 1.04 (95% CI, 0.91-1.19; P = .58).

Conclusions and Relevance

In this retrospective cohort study of pediatric in-hospital CPR, several factors, including age and event location, were associated with CPR duration in event nonsurvivors. The odds of survival to discharge were lower for patients at hospitals with the shortest and longest median CPR durations among events without ROC. Further studies are needed to determine the optimal duration of CPR during pediatric in-hospital cardiac arrest and to provide training guidelines for resuscitation teams to eliminate disparities in resuscitation care.

Cognitive outcome and its neural correlates after cardiorespiratory arrest in childhood

Hypoxia-ischaemia (HI) can result in structural brain abnormalities, which in turn can lead to behavioural deficits in various cognitive and motor domains, in both adult and paediatric populations. Cardiorespiratory arrest (CA) is a major cause of hypoxia-ischaemia in adults, but it is relatively rare in infants and children. While the effects of adult CA on brain and cognition have been widely studied, to date, there are no studies examining the neurodevelopmental outcome of children who suffered CA early in life. Here, we studied the long-term outcome of 28 children who suffered early CA (i.e., before age 16). They were compared to a group of control participants (n = 28) matched for age, sex and socio-economic status. The patient group had impairments in the domains of memory, language and academic attainment (measured using standardised tests). Individual scores within the impaired range were most commonly found within the memory domain (79%), followed by academic attainment (50%), and language (36%). The patient group also had reduced whole brain grey matter volume, and reduced volume and fractional anisotropy of the white matter. In addition, lower performance on memory tests was correlated with bilaterally reduced volume of the hippocampi, thalami, and striatum, while lower attainment scores were correlated with bilateral reduction of fractional anisotropy in the superior cerebellar peduncle, the main output tract of the cerebellum. We conclude that patients who suffered early CA are at risk of developing specific cognitive deficits associated with structural brain abnormalities. RESEARCH HIGHLIGHTS: Our data shed light on the long-term outcome and associated neural mechanisms after paediatric hypoxia-ischaemia as a result of cardiorespiratory arrest. Patients had impaired scores on memory, language and academic attainment. Memory impairments were associated with smaller hippocampi, thalami, and striatum. Lower academic attainment correlated with reduced fractional anisotropy of the superior cerebellar peduncle.

Ferroptosis-related gene MAPK3 is associated with the neurological outcome after cardiac arrest

BACKGROUND

Neuronal ferroptosis is closely related to the disease of the nervous system, and the objective of the present study was to recognize and verify the potential ferroptosis-related genes to forecast the neurological outcome after cardiac arrest.

METHODS

Cardiac Arrest-related microarray datasets GSE29540 and GSE92696 were downloaded from GEO and batch normalization of the expression data was performed using "sva" of the R package. GSE29540 was analyzed to identify DEGs. Venn diagram was applied to recognize ferroptosis-related DEGs from the DEGs. Subsequently, The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were performed, and PPI network was applied to screen hub genes. Receiver operating characteristic (ROC) curves were adopted to determine the predictive value of the biomarkers, and the GSE92696 dataset was applied to further evaluate the diagnostic efficacy of the biomarkers. We explore transcription factors and miRNAs associated with hub genes. The "CIBERSORT" package of R was utilized to analyse the proportion infiltrating immune cells. Finally, validated by a series of experiments at the cellular level.

RESULTS

112 overlapping ferroptosis-related DEGs were further obtained via intersecting these DEGs and ferroptosis-related genes. The GO and KEGG analysis demonstrate that ferroptosis-related DEGs are mainly involved in response to oxidative stress, ferroptosis, apoptosis, IL-17 signalling pathway, autophagy, toll-like receptor signalling pathway. The top 10 hub genes were selected, including HIF1A, MAPK3, PPARA, IL1B, PTGS2, RELA, TLR4, KEAP1, SREBF1, SIRT6. Only MAPK3 was upregulated in both GSE29540 and GAE92696. The AUC values of the MAPK3 are 0.654 and 0.850 in GSE29540 and GSE92696 respectively. The result of miRNAs associated with hub genes indicates that hsa-miR-214-3p and hsa-miR-483-5p can regulate the expression of MAPK3. MAPK3 was positively correlated with naive B cells, macrophages M0, activated dendritic cells and negatively correlated with activated CD4 memory T cells, CD8 T cells, and memory B cells. Compared to the OGD4/R24 group, the OGD4/R12 group had higher MAPK3 expression at both mRNA and protein levels and more severe ferroptosis.

CONCLUSION

In summary, the MAPK3 ferroptosis-related gene could be used as a biomarker to predict the neurological outcome after cardiac arrest. Potential biological pathways provide novel insights into the pathogenesis of 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.

Advances in pediatric emergency from 2023

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Association of Pediatric Postcardiac Arrest Ventilation and Oxygenation with Survival Outcomes

Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, compared with postarrest normoxemia, and whether postarrest hypocapnia or hypercapnia is associated with lower rates of survival, compared with postarrest normocapnia. Methods: An embedded prospective observational study during a multicenter interventional cardiopulmonary resuscitation trial was conducted from 2016 to 2021. Patients ⩽18 years old and with a corrected gestational age of ≥37 weeks who received chest compressions for cardiac arrest in one of the 18 intensive care units were included. Exposures during the first 24 hours postarrest were hypoxemia, hyperoxemia, or normoxemia-defined as lowest arterial oxygen tension/pressure (PaO2) <60 mm Hg, highest PaO2 ⩾200 mm Hg, or every PaO2 60-199 mm Hg, respectively-and hypocapnia, hypercapnia, or normocapnia, defined as lowest arterial carbon dioxide tension/pressure (PaCO2) <30 mm Hg, highest PaCO2 ⩾50 mm Hg, or every PaCO2 30-49 mm Hg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. Results: The hypoxemia group was less likely to survive to hospital discharge, compared with the normoxemia group (adjusted relative risk [aRR] = 0.71; 95% confidence interval [CI] =  0.58-0.87), whereas survival in the hyperoxemia group did not differ from that in the normoxemia group (aRR = 1.0; 95% CI = 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge, compared with the normocapnia group (aRR = 0.74; 95% CI = 0.64-0.84), whereas survival in the hypocapnia group did not differ from that in the normocapnia group (aRR = 0.91; 95% CI = 0.74-1.12). Conclusions: Postarrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.

Improvement of the rapid response system at an acute rehabilitation hospital in New Mexico

Aim: Enhance the Rapid Response System (RRS) in a free-standing acute rehabilitation hospital (ARH) by improving announcements, crash cart standardization and role assignments. Materials & methods: Pre-intervention (PreIQ) and post-intervention questionnaires (PostIQ), conducted in English and utilizing a Likert scale, were distributed in-person to clinical staff, yielding a 100% response rate. The questionnaire underwent no prior testing. The PreIQ were disseminated in February 2021, and PostIQ in December 2022. Results: PostIQ illustrated the improvement of audibility and improved the clarity of roles. The training positively impacted the RRS in the ARH. Conclusion: This study highlights the value of continuous RRS improvement in ARHs. Interventions led to notable enhancements, emphasizing the need for sustained efforts and future research on broader implementation.

Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest

BACKGROUND

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes.

METHODS

In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes.

RESULTS

We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes.

CONCLUSIONS

Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Association between survival and number of shocks for pulseless ventricular arrhythmias during pediatric in-hospital cardiac arrest in a national registry

BACKGROUND

Annually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA.

METHODS

Using 2000-2020 data from the American Heart Association's (AHA) Get with the Guidelines®-Resuscitation (GWTG-R) registry, we identified children >48 hours of life and ≤18 years who had an IHCA from initial VF/pVT and received defibrillation.

RESULTS

There were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation.

CONCLUSIONS

In pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.

Cerebral Oximetry During Pediatric In-Hospital Cardiac Arrest: A Multicenter Study of Survival and Neurologic Outcome

OBJECTIVES

To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children.

DESIGN

Multicenter, observational study.

SETTING

Three hospitals in the pediatric Resuscitation Quality (pediRES-Q) collaborative from 2015 to 2022.

PATIENTS

Children younger than 18 years, gestational age 37 weeks old or older with in-hospital cardiac arrest (IHCA) receiving cardiopulmonary resuscitation greater than or equal to 1 minute and intra-arrest crS o2 monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was ROSC greater than or equal to 20 minutes without extracorporeal membrane oxygenation. Secondary outcomes included SHD and favorable neurologic outcome (FNO) (Pediatric Cerebral Performance Category 1-2 or no change from prearrest). Among 3212 IHCA events (index and nonindex), 123 met inclusion criteria in 93 patients. Median age was 0.3 years (0.1-1.4 yr) and 31% (38/123) of the cardiopulmonary resuscitation events occurred in patients with cyanotic heart disease. Median cardiopulmonary resuscitation duration was 8 minutes (3-28 min) and ROSC was achieved in 65% (80/123). For index events, SHD was achieved in 59% (54/91) and FNO in 41% (37/91). We determined the association of median intra-arrest crS o2 and percent of crS o2 values above a priori thresholds during the: 1) entire cardiopulmonary resuscitation event, 2) first 5 minutes, and 3) last 5 minutes with ROSC, SHD, and FNO. Higher crS o2 for the entire cardiopulmonary resuscitation event, first 5 minutes, and last 5 minutes were associated with higher likelihood of ROSC, SHD, and FNO. In multivariable analysis of the infant group (age < 1 yr), higher crS o2 was associated with ROSC (odds ratio [OR], 1.06; 95% CI, 1.03-1.10), SHD (OR, 1.04; 95% CI, 1.01-1.07), and FNO (OR, 1.05; 95% CI, 1.02-1.08) after adjusting for presence of cyanotic heart disease.

CONCLUSIONS

Higher crS o2 during pediatric IHCA was associated with increased rate of ROSC, SHD, and FNO. Intra-arrest crS o2 may have a role as a real-time, noninvasive predictor of ROSC.