Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States

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.

Improving the Quality of Pediatric Basic Life Support Cardiopulmonary Resuscitation With a Novel Method: The Maryland Hiccup

Prehospital high-performance cardiopulmonary resuscitation (CPR) has demonstrated remarkable improvements in the survival of adult patients after out-of-hospital cardiac arrest (OHCA). With a goal to improve pediatric survival rates, Maryland Emergency Medical Services (EMS) for Children created a pediatric-specific high-performance CPR protocol to align with the existing state protocol for adult CPR. While prehospital CPR for adults has moved toward continuous compressions, prehospital CPR for children without an advanced airway continues to adhere to American Heart Association (AHA)/International Liaison Committee on Resuscitation (ILCOR) guidance for two ventilations for every 15 compressions. The Maryland Hiccup (MH) is a novel approach to pediatric CPR. The method combines the goal of continuous compressions with AHA/ILCOR guidance for a 15:2 compression-to-ventilation ratio. In contrast to the two- to four-second pause after compression 15 of the AHA/ILCOR style, the "hiccup" of the MH method describes two brief pauses for ventilation during the upstrokes of compressions 14 and 15. We compare basic CPR quality metrics for two-rescuer high-performance CPR using the standard AHA/ILCOR 15:2 style compared to the MH style. We enrolled 38 Maryland EMS clinicians in two-person teams to perform simulated CPR on a pediatric manikin. We recorded compression and ventilation data for 76 two-minute cycles of high-performance CPR. Compression fraction was significantly improved using the MH when compared to the standard AHA style for high-performance CPR (median 98% vs 80%, p<0.001). When compressions per minute (CPM) were compared by 30-second epochs, 80% of epochs were out of range (<100 CPM or >120 CPM) using the AHA/ILCOR style, while only 32% of epochs were out of range for MH style. No significant differences were found between the two CPR styles in ventilation volume or compression depth. The MH is a novel method for pediatric basic life support two-provider CPR which improves CPR quality metrics among EMS clinicians regardless of their prior experience. The use of this method in simulation allows near-continuous compressions without the placement of an advanced airway. Future research is needed to explore whether the CPR quality improvements translate to improved patient outcomes in real-world use.

Endogenous recovery of hippocampal function following global cerebral ischemia in juvenile female mice is influenced by neuroinflammation and circulating sex hormones

Cardiac arrest-induced global cerebral ischemia (GCI) in childhood often results in learning and memory deficits. We previously demonstrated in a murine cardiac arrest and cardiopulmonary resuscitation (CA/CPR) mouse model that a cellular mechanism of learning and memory, long-term potentiation (LTP), is acutely impaired in the hippocampus of juvenile males, correlating with deficits in memory tasks. However, little is known regarding plasticity impairments in juvenile females. We performed CA/CPR in juvenile (P21-25) female mice and used slice electrophysiology and hippocampal dependent behavior to assess hippocampal function. LTP was and contextual fear were impaired 7-days after GCI and endogenously recovered by 30-days. LTP remained impaired at 30 days in ovariectomized females, suggesting the surge in gonadal sex hormones during puberty mediates endogenous recovery. Unlike juvenile males, recovery of LTP in juvenile females was not associated with BDNF expression. NanoString transcriptional analysis revealed a potential role of neuroinflammatory processes, and specifically Cd68 pathways, in LTP impairment and hormone-dependent recovery. We were able to restore LTP in ovariectomized females with chronic and acute PPT administration, implicating estrogen receptor alpha in recovery mechanisms. This study supports a mechanism of endogenous LTP recovery after GCI in juvenile female mice which differs mechanistically from juvenile males and does not occur in adults of either sex.

An open window: the crucial role of the gut-brain axis in neurodevelopmental outcomes post-neurocritical illness

Among patients admitted to the pediatric intensive care unit, approximately 10% are discharged with a new functional morbidity. For those who were admitted with a neurocritical illness, the number can be as high as 60%. The most common diagnoses for a neurocritical illness admission include traumatic brain injury, status epilepticus, post-cardiac arrest, hypoxic ischemic encephalopathy, meningo/encephalitis, and stroke. The gut-brain axis is crucial to childhood development, particularly neurodevelopment. Alterations on either side of the bidirectional communication of the gut-brain axis have been shown to alter typical development and have been associated with autism spectrum disorder, anxiety, sleep disturbances, and learning disabilities, among others. For those patients who have experienced a direct neurologic insult, subsequent interventions may contribute to dysbiosis, which could compound injury to the brain. Increasing data suggests the existence of a critical window for both gut microbiome plasticity and neurodevelopment in which interventions could help or could harm and warrant further investigation.

Incidence of cardiac arrest following implementation of a predictive analytics display in a pediatric intensive care unit

Background

More than 90% of in-hospital cardiac arrests involving children occur in an intensive care unit (ICU) with less than half surviving to discharge. We sought to assess the association of the display of risk scores of cardiovascular and respiratory instability with the incidence of cardiac arrest in a pediatric ICU.

Methods

Employing supervised machine learning, we previously developed predictive models of cardiovascular and respiratory instability, incorporating real-time physiologic and laboratory data, to display risk scores for potentially catastrophic clinical events in the subsequent 12 h. Clinical implementation with risk scores displayed on large screen monitors in multiple areas throughout the ICU was finalized in July 2022. We compared the incidence of cardiac arrest events in the 18-months pre- and post-implementation.

Results

The cardiac arrest incidence rate dropped from 3.0 events (95% CI 2.0-4.4) to 2.4 events (95% CI 1.6-3.5) per 1000 patient days following implementation. We observed a 50% increase in the rate of cardiac arrest events where return of spontaneous circulation (ROSC) was achieved (p = 0.025). The incidence rate of cardiac arrest without ROSC dropped from 1.4 events (95% CI 0.7-2.4) to 0.4 events (95% CI 0.1-0.9) per 1000 patient days (incidence rate difference = 1.0 (95% CI 0.13-1.87), p = 0.01).

Conclusions

We observed a non-significant decrease in the rates of cardiac arrest events and an increase in the rate of cardiac arrests events where ROSC was achieved following the implementation of a predictive analytics display of risk scores.

A novel translational bioinformatics framework for facilitating multimodal data analyses in preclinical models of neurological injury

Pediatric neurological injury and disease is a critical public health issue due to increasing rates of survival from primary injuries (e.g., cardiac arrest, traumatic brain injury) and a lack of monitoring technologies and therapeutics for treatment of secondary neurological injury. Translational, preclinical research facilitates the development of solutions to address this growing issue but is hindered by a lack of available data frameworks and standards for the management, processing, and analysis of multimodal datasets. Here, we present a generalizable data framework that was implemented for large animal research at the Children's Hospital of Philadelphia to address this technological gap. The presented framework culminates in a custom, interactive dashboard for exploratory analysis and filtered dataset download. Compared with existing clinical and preclinical data management solutions, the presented framework better enables management of various data types (single measure, repeated measures, time series, and imaging), integration of datasets for comparison across experimental models, cohorts, and groups, and facilitation of predictive modeling from integrated datasets. Further, a predictive model development use case demonstrated utilization and value of the data framework. The general outline of a preclinical data framework presented here can serve as a template for other translational research labs that generate heterogeneous datasets and require a dynamic platform that can easily evolve alongside their research.

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.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Development and testing of a resuscitation-specific measure of organizational culture for resuscitation teams

Background

The organizational culture (shared beliefs, perceptions, and values) of teams informs their behaviours and practices. Little is known about organizational culture for resuscitation teams. Our objective was to develop a reliable and valid resuscitation-specific organizational culture instrument (ROCI) with the goal of improving team performance.

Methods

Using Neonatal Resuscitation Program principles, literature review, and discussion of existing culture measures with experts, we identified organizational culture components for resuscitation and adapted existing measures to resuscitation. We developed a ROCI with five subscales (role clarity, shared-mental models, closed-loop communication, team adaptability, and psychological safety) and administered it to neonatal resuscitation team members across a hospital network. Survey psychometric assessment included reliability analyses (Cronbach's α, Pearson correlation coefficients) and validity testing (confirmatory factor analysis [CFA] and regression models examining the association of culture with implementation outcomes: climate and perceived success).

Results

Across 11 hospitals there were 318 complete responses (41 % response rate). Of the 22-items tested, 18 were retained after iterative psychometric assessment. The ROCI had excellent overall reliability (Cronbach's α = 0.994) and very good subscale reliability (Cronbach's α = 0.789-0.867). The CFA goodness-of-fit statistics confirmed five constructs (subscales). At the individual-level, the ROCI and all subscales were associated with both implementation outcomes. At the hospital-level, the ROCI overall and three subscales were associated with perceived success.

Conclusion

The ROCI is a reliable and valid measure of the organizational culture of resuscitation teams. Future ROCI assessments may provide a foundation to inform culture change initiatives to improve resuscitation quality and outcomes across populations and contexts.

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.

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.

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.

The impact of pediatric post-cardiac arrest care on survival: A multicenter review from the AHA get with the Guidelines®-resuscitation post-cardiac arrest care registry

AIM

Adherence to post-cardiac arrest care (PCAC) recommendations is associated with improved outcomes for adults. We aimed to describe the survival impact of meeting American Heart Association (AHA) PCAC guidelines in children after cardiac arrest.

METHODS

We conducted a retrospective study using Get With The Guidelines® Resuscitation's (GWTG®-R) registry to describe the PCAC of patients ≤ 18 years old who suffered an in-hospital or out-of-hospital cardiac arrest (IHCA or OHCA). We evaluated the association between the absence of hypotension and fever in the initial 24 h following return of circulation (ROC) with survival to hospital discharge. We reviewed the utilization of monitoring/evaluation tools recommended in pediatric PCAC guidelines: electrocardiogram (ECG), electroencephalogram (EEG), and neuro-imaging.

RESULTS

We found 385 pediatric patients who suffered an IHCA or OHCA from 2015 through 2019 and survived at least 6 h post-ROC. Sixty-six percent of patients survived to hospital discharge. Following ROC, 56% of patients had EEG monitoring, 80% had an ECG performed, 47% had a head CT, and 26% had a cerebral MRI. In the initial 24 h post-ROC, 92% of patients did not have hypotension and 79% were afebrile. Patients without hypotension in the initial 24 h post-ROC had higher odds of survival to hospital discharge than those with hypotension (aOR 4.96; 95% CI 2.07, 11.90; p = 0.0003), adjusting for age and cardiac arrest location. Patients without hypotension and without fever in the initial 24 h post-ROC had higher odds of survival to hospital discharge compared to patients who had either hypotension or fever or both (aOR 1.98; 95% CI 1.06,3.71; p = 0.034).

CONCLUSION

In this retrospective multicenter registry study, absence of both post-cardiac arrest hypotension and fever were associated with increased odds of survival to hospital discharge. Further research is needed to understand the full impact of PCAC recommendation compliance on survival outcomes.

Outcomes in pediatric extracorporeal cardiopulmonary resuscitation: A single-center retrospective study from 2007 to 2022 in China

OBJECTIVE

We aimed to investigate the prognostic factors of pediatric extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

The retrospective study included a total of 77 pediatric cases (7 neonates and 70 children) who underwent ECPR after in-hospital and out-of-hospital cardiac arrest between July 2007 and December 2022. Primary endpoints were complications, while secondary endpoints included all-cause in-hospital mortality.

RESULTS

Among the 45 cases experiencing complications, 4 neonates and 41 children had multiple simultaneous complications, primarily neurological issues in 25 cases. Additionally, organ failure occurred in 11 cases, and immunodeficiency was present in two cases. Furthermore, 9 cases experienced bleeding events, and 13 cases showed thrombosis. Patients with complications had lower weight, shorter ECMO durations, and longer CPR durations. Non-survivors had longer CPR durations and shorter durations of ECMO, ICU stay, and mechanical ventilation compared to survivors. Complications were more prevalent in non-survivors, particularly organ failure and bleeding events.

CONCLUSION

Weight, CPR duration, and ECMO duration were associated with complications, suggesting areas for treatment optimization. The higher occurrence of complications in non-survivors underscores the importance of early detection and management to improve survival rates. Our findings suggest clinicians consider these factors in prognostic assessments to enhance the effectiveness of ECPR programs.

Association of EEG characteristics with outcomes following pediatric ICU cardiac arrest: A secondary analysis of the ICU-RESUScitation trial

BACKGROUND AND OBJECTIVES

There are limited tools available following cardiac arrest to prognosticate neurologic outcomes. Prior retrospective and single center studies have demonstrated early EEG features are associated with neurologic outcome. This study aimed to evaluate the prognostic value of EEG for pediatric in-hospital cardiac arrest (IHCA) in a prospective, multicenter study.

METHODS

This cohort study is a secondary analysis of the ICU-Resuscitation trial, a multicenter randomized interventional trial conducted at 18 pediatric and pediatric cardiac ICUs in the United States. Patients who achieved return of circulation (ROC) and had post-ROC EEG monitoring were eligible for inclusion. Patients < 90 days old and those with pre-arrest Pediatric Cerebral Performance Category (PCPC) scores > 3 were excluded. EEG features of interest included EEG Background Category, and presence of focal abnormalities, sleep spindles, variability, reactivity, periodic and rhythmic patterns, and seizures. The primary outcome was survival to hospital discharge with favorable neurologic outcome. Associations between EEG features and outcomes were assessed with multivariable logistic regression. Prediction models with and without EEG Background Category were developed and receiver operator characteristic curves compared.

RESULTS

Of the 1129 patients with an index cardiac arrest who achieved ROC in the parent study, 261 had EEG within 24 h of ROC, of which 151 were evaluable. The cohort included 57% males with a median age of 1.1 years (IQR 0.4, 6.8). EEG features including EEG Background Category, sleep spindles, variability, and reactivity were associated with survival with favorable outcome and survival, (all p < 0.001). The addition of EEG Background Category to clinical models including age category, illness category, PRISM score, duration of CPR, first documented rhythm, highest early post-arrest arterial lactate improved the prediction accuracy achieving an AUROC of 0.84 (CI 0.77-0.92), compared to AUROC of 0.76 (CI 0.67-0.85) (p = 0.005) without EEG Background Category.

CONCLUSION

This multicenter study demonstrates the value of EEG, in the first 24 h following ROC, for predicting survival with favorable outcome after a pediatric IHCA.

Association of diastolic blood pressure with coronary perfusion pressure during resuscitation in pediatric swine

BACKGROUND

Diastolic blood pressure (DBP) is suggested as a surrogate for coronary perfusion pressure (CPP) during cardiopulmonary resuscitation. We examined the correlation between DBP and CPP and hypothesized that both would be associated with survival in a pediatric swine model of asphyxial cardiac arrest.

METHODS

We performed a retrospective, secondary analysis of 102 pediatric swine resuscitations. DBP and CPP were recorded every 30 s during resuscitation. Values were compared between survivors and non-survivors.

RESULTS

DBP mirrored CPP in survivors and non-survivors throughout resuscitation and both were associated with survival. Improvements in DBP and CPP after the first epinephrine administration were greater in survivors (DBP: 25.1 ± 3.0 vs. 5.4 ± 0.8 mmHg, p < 0.01; CPP: 24.9 ± 3.2 vs. 4.8 ± 0.9 mmHg, p < 0.01). DBP and CPP after epinephrine administration were highly predictive of survival, with an area under the curve of 0.95 (0.89-1.00) for DBP and 0.90 (0.81-0.99) for CPP. The optimal threshold for DBP was 22.5 mmHg, whereas that for CPP was 14.5 mmHg.

CONCLUSIONS

DBP and CPP were associated with survival throughout resuscitation, and the response of both to the first epinephrine administration was highly predictive of survival in this model. Clinically, the availability of DBP makes it useful as a target for physiologic feedback during resuscitation.

IMPACT

Diastolic blood pressure (DBP) mirrored coronary perfusion pressure (CPP) throughout prolonged resuscitation in a pediatric model of asphyxial cardiac arrest. Mean DBP and CPP were significantly greater in survivors than in non-survivors both before and after administration of epinephrine. The response of both DBP and CPP to the first dose of epinephrine was highly predictive of return of spontaneous circulation. Given the clinical availability of DBP, these findings support its use as a surrogate for CPP to guide high-quality cardiopulmonary resuscitation in this pediatric swine model.

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.

Pediatric Tele-Critical Care: Initial Experience with a Continuous Surveillance Model Aiming to Prevent Cardiac Arrest in Children with Critical Heart Disease

Introduction: Despite advances in treatment of children with critical heart disease, cardiac arrest (CA) remains a common occurrence. We provided virtual support to bedside teams (BTs) from a tele-critical care (TCC) unit in a pediatric cardiac intensive care unit (CICU) and focused on early detection of concerning trends (CT) and avoidance of CA. Virtual surveillance workflows included a review of remote monitoring, video feed from patient room cameras, medical records, and artificial intelligence tools. We present our initial experience with a focus on critical communications (CCs) to BTs. Methods: A retrospective, descriptive review of TCC activities was conducted from January 2019 to December 2022, involving electronic databases and electronic medical records of patients in the CICU, including related CCs to BTs, responses from BTs, and related CA. Results: We conducted 18,171 TCC activities, including 2,678 non-CCs and 248 CCs. Over time, there was a significant increase in the proportion of CCs related with CT (p = 0.002), respiratory concerns (<0.001), and abnormalities in cardiac rhythm (p = 0.04). Among a sample of 244 CCs, subsequent interventions by BTs resulted in adjustment of medical treatment (127), respiratory support (68), surgery or intervention (19), cardiac rhythm control (17), imaging study (14), early resuscitation (9), and others (10). Conclusions: CCs from a TCC unit in a pediatric CICU changed over time with an increased focus on CT and resulted in early interventions, potentially contributing to avoiding CA. This model of care in pediatric cardiac critical care has the potential to improve patient safety.

Management of Paediatric Cardiac Arrest due to Shockable Rhythm-A Simulation-Based Study at Children's Hospitals in a German Federal State

(1) Background: To improve the quality of emergency care for children, the Hessian Ministry for Social Affairs and Integration offered paediatric simulation-based training (SBT) for all children's hospitals in Hesse. We investigated the quality of paediatric life support (PLS) in simulated paediatric resuscitations before and after SBT. (2) Methods: In 2017, a standardised, high-fidelity, two-day in-house SBT was conducted in 11 children's hospitals. Before and after SBT, interprofessional teams participated in two study scenarios (PRE and POST) that followed the same clinical course of apnoea and cardiac arrest with a shockable rhythm. The quality of PLS was assessed using a performance evaluation checklist. (3) Results: 179 nurses and physicians participated, forming 47 PRE and 46 POST interprofessional teams. Ventilation was always initiated. Before SBT, chest compressions (CC) were initiated by 87%, and defibrillation by 60% of teams. After SBT, all teams initiated CC (p = 0.012), and 80% defibrillated the patient (p = 0.028). The time to initiate CC decreased significantly (PRE 123 ± 11 s, POST 76 ± 85 s, p = 0.030). (4) Conclusions: The quality of PLS in simulated paediatric cardiac arrests with shockable rhythm was poor in Hessian children's hospitals and improved significantly after SBT. To improve children's outcomes, SBT should be mandatory for paediatric staff and concentrate on the management of shockable rhythms.

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.

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.

Identifying Gaps in Resuscitation Practices Across Level-IV Neonatal Intensive Care Units

OBJECTIVES

This study aimed to describe resuscitation practices in level-IV neonatal intensive care units (NICUs) and identify possible areas of improvement.

STUDY DESIGN

This study was a cross-sectional cohort survey and conducted at the Level-IV NICUs of Children's Hospital Neonatal Consortium (CHNC). The survey was developed with consensus from resuscitation and education experts in the CHNC and pilot tested. An electronic survey was sent to individual site sponsors to determine unit demographics, resuscitation team composition, and resuscitation-related clinical practices.

RESULTS

Of the sites surveyed, 33 of 34 sites responded. Unit average daily census ranged from less than 30 to greater than 100, with the majority (72%) of the sites between 30 and 75 patients. A designated code response team was utilized in 18% of NICUs, only 30% assigned roles before or during codes. The Neonatal Resuscitation Program (NRP) was the exclusive algorithm used during codes in 61% of NICUs, and 34% used a combination of NRP and the Pediatric Advanced Life Support (PALS). Most (81%) of the sites required neonatal attendings to maintain NRP training. A third of sites (36%) lacked protocols for high-acuity events. A code review process existed in 76% of participating NICUs, but only 9% of centers enter code data into a national database.

CONCLUSION

There is variability among units regarding designated code team presence and composition, resuscitation algorithm, protocols for high-acuity events, and event review. These inconsistencies in resuscitation teams and practices provide an opportunity for standardization and, ultimately, improved resuscitation performance. Resources, education, and efforts could be directed to these areas to potentially impact future neonatal outcomes of the complex patients cared for in level-IV NICUs.

KEY POINTS

· Resuscitation practice is variable in level-IV NICUs.. · Resuscitation algorithm training is not uniform. · Standardized protocols for high-acuity low-occurrence (HALO) events are lacking.

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis

IMPORTANCE

A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis.

OBJECTIVES

We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database.

MAIN OUTCOMES AND MEASURES

The primary exposure was NIPPV and the primary outcome was IHCA.

MEASUREMENTS AND MAIN RESULTS

Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]).

CONCLUSIONS AND RELEVANCE

Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

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.

Higher Survival With the Use of Extracorporeal Cardiopulmonary Resuscitation Compared With Conventional Cardiopulmonary Resuscitation in Children Following Cardiac Surgery: Results of an Analysis of the Get With The Guidelines-Resuscitation Registry

OBJECTIVES

Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation (CPR) is increasingly used in children suffering cardiac arrest after cardiac surgery. However, its efficacy in promoting survival has not been evaluated. We compared survival of pediatric cardiac surgery patients suffering in-hospital cardiac arrest who were resuscitated with extracorporeal CPR (E-CPR) to those resuscitated with conventional CPR (C-CPR) using propensity matching.

DESIGN

Retrospective study using multicenter data from the American Heart Association Get With The Guidelines-Resuscitation registry (2008-2020).

SETTING

Multicenter cardiac arrest database containing cardiac arrest and CPR data from U.S. hospitals.

PATIENTS

Cardiac surgical patients younger than 18 years old who suffered in-hospital cardiac arrest and received greater than or equal to 10 minutes of CPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 1223 patients, 741 (60.6%) received C-CPR and 482 (39.4%) received E-CPR. E-CPR utilization increased over the study period ( p < 0.001). Duration of CPR was longer in E-CPR compared with C-CPR recipients (42 vs. 26 min; p < 0.001). In a propensity score matched cohort (382 E-CPR recipients, 382 C-CPR recipients), E-CPR recipients had survival to discharge (odds ratio [OR], 2.22; 95% CI, 1.7-2.9; p < 0.001). E-CPR survival was only higher when CPR duration was greater than 18 minutes. Propensity matched analysis using patients from institutions contributing at least one E-CPR case ( n = 35 centers; 353 E-CPR recipients, 353 C-CPR recipients) similarly demonstrated improved survival in E-CPR recipients compared with those who received C-CPR alone (OR, 2.08; 95% CI, 1.6-2.8; p < 0.001).

CONCLUSIONS

E-CPR compared with C-CPR improved survival in children suffering cardiac arrest after cardiac surgery requiring CPR greater than or equal to 10 minutes.

Outcomes of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest Among Children With Noncardiac Illness Categories

OBJECTIVES

The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years.

DESIGN

Retrospective multicenter cohort study.

SETTING

Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021.

PATIENTS

Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time ( p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis ( p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge.

CONCLUSIONS

ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).

Organization and training for pediatric cardiac arrest in Danish hospitals: A nationwide cross-sectional study

Background

Improving survival from pediatric cardiac arrest requires a well-functioning system of care with appropriately trained healthcare providers and designated cardiac arrest teams. This study aimed to describe the current organization and training for pediatric cardiac arrest in Denmark.

Methods

 We performed a nationwide cross-sectional study. A questionnaire was distributed to all hospitals in Denmark with a pediatric department. The survey included questions about receiving patients with out-of-hospital cardiac arrest, protocols for extracorporeal life support, cardiac arrest team compositions, and training.

Results

We obtained responses from 17 of 19 hospitals with a pediatric department. In total, 76% of hospitals received patients with pediatric out-of-hospital cardiac arrest and 35% of hospitals had a protocol for extracorporeal life support. None of the hospitals had identical cardiac arrest team member compositions. The total number of team members ranged from 4-10, with a median of 8 members (IQR 7;9). In 84% of hospitals a specialized course in pediatric resuscitation was implemented and in 5% of hospitals, the specialized course was for the entire cardiac arrest team. Only few hospitals had training in laryngeal mask (6%) and intubation (29%) for pediatric cardiac arrest and none of them were trained in extracorporeal life support.

Conclusion

We found high variability in the composition of the pediatric cardiac arrest teams and training across the surveyed Danish hospitals. Many hospitals lack training in important pediatric resuscitation skills. Although many hospitals receive pediatric patients after out-of-hospital cardiac arrest, only few have protocols for transfer for extracorporeal life support.

2024 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 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

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.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

Importance

Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival.

Objective

To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA.

Design, Setting, and Participants

This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023.

Main Outcomes and Measure

Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose).

Results

A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6).

Conclusions and Relevance

In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AIM

Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes.

METHODS AND RESULTS

Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes.

CONCLUSIONS

Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease

OBJECTIVES

To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.

DESIGN

Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021).

SETTING

Eighteen PICUs.

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.

CONCLUSIONS

In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.

Injury patterns and mortality associated with near-hanging in children

BACKGROUND

The pathophysiology of near-hanging in children is different from that of adults due to anatomic, physiologic, and injury-related mechanisms, with evidence suggesting that blunt cerebrovascular injuries (BCVI) and cervical spine injuries (CSI) are uncommon. We sought to estimate the incidence of secondary injuries and their association with mortality in pediatric near-hanging victims.

METHODS

We performed a retrospective observational study of children (≤17 years) with a diagnosis code for hanging between October 1, 2015 and February 28, 2023 who presented to one of 47 geographically diverse US children's hospitals. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI. We performed Fisher's exact test with Bonferroni correction to identify associations between intentionality, sex, age, and secondary injuries with mortality.

RESULTS

We included 1929 children, of whom 33.8% underwent neuroimaging, 45.9% underwent neck imaging, and 38.7% underwent neck angiography. The most common injury was cerebral edema (24.0%), followed by pulmonary edema (3.2%) and pneumothorax (2.8%). CSI (2.1%) and BCVI (0.9%) occurred infrequently. Cerebral edema, pneumothorax, pulmonary edema, and younger age (≤12 years) were associated with mortality.

CONCLUSIONS

In this multi-center study of pediatric near-hanging victims, BCVI and CSI occurred rarely and were not associated with mortality. While children in our study underwent neck imaging more frequently than head imaging, cerebral edema occurred more often than other injury types and imparted the highest mortality risk. Given the rarity of BCVI and CSI, a selective approach to neck imaging may be warranted in pediatric near-hanging events.

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

INTRODUCTION

Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

METHODS

We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

RESULTS

Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

CONCLUSIONS

Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.

Impaired echocardiographic left ventricular global longitudinal strain after pediatric cardiac arrest children is associated with mortality

BACKGROUND

Global longitudinal strain (GLS) is an echocardiographic method to identify left ventricular (LV) dysfunction after cardiac arrest that is less sensitive to loading conditions. We aimed to identify the frequency of impaired GLS following pediatric cardiac arrest, and its association with hospital mortality.

METHODS

This is a retrospective single-center cohort study of children <18 years of age treated in the pediatric intensive care unit (PICU) after in- or out-of-hospital cardiac arrest (IHCA and OHCA), with echocardiogram performed within 24 hours of initiation of post-arrest PICU care between 2013 and 2020. Patients with congenital heart disease, post-arrest extracorporeal support, or inability to measure GLS were excluded. Echocardiographic LV ejection fraction (EF) and shortening fraction (SF) were abstracted from the chart. GLS was measured post hoc; impaired strain was defined as LV GLS ≥ 2 SD worse than age-dependent normative values. Demographics and pre-arrest, arrest, and post-arrest characteristics were compared between subjects with normal versus impaired GLS. Correlation between GLS, SF and EF were calculated with Pearson comparison. Logistic regression tested the association of GLS with mortality. Area under the receiver operator curve (AUROC) was calculated for discriminative utility of GLS, EF, and SF with mortality.

RESULTS

GLS was measured in 124 subjects; impaired GLS was present in 46 (37.1%). Subjects with impaired GLS were older (median 7.9 vs. 1.9 years, p < 0.001), more likely to have ventricular tachycardia/fibrillation as initial rhythm (19.6% versus 3.8%, p = 0.017) and had higher peak troponin levels in the first 24 hours post-arrest (median 2.5 vs. 0.5, p = 0.002). There were no differences between arrest location or CPR duration by GLS groups. Subjects with impaired GLS compared to normal GLS had lower median EF (42.6% versus 62.3%) and median SF (23.3% versus 36.6%), all p < 0.001, with strong inverse correlation between GLS and EF (rho -0.76, p < 0.001) and SF (rho -0.71, p < 0.001). Patients with impaired GLS had higher rates of mortality (60% vs. 32%, p = 0.009). GLS was associated with mortality when controlling for age and initial rhythm [aOR 1.17 per 1% increase in GLS (95% CI 1.09-1.26), p < 0.001]. GLS, EF and SF had similar discrimination for mortality: GLS AUROC 0.69 (95% CI 0.60-0.79); EF AUROC 0.71 (95% CI 0.58-0.88); SF AUROC 0.71 (95% CI 0.61-0.82), p = 0.101.

CONCLUSIONS

Impaired LV function as measured by GLS after pediatric cardiac arrest is associated with hospital mortality. GLS is a novel complementary metric to traditional post-arrest echocardiography that correlates strongly with EF and SF and is associated with mortality. Future large prospective studies of post-cardiac arrest care should investigate the prognostic utilities of GLS, alongside SF and EF.

Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest

AIM

To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest.

METHODS

This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status.

RESULTS

Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites.

CONCLUSIONS

Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.

The association of arterial blood pressure waveform-derived area duty cycle with intra-arrest hemodynamics and cardiac arrest outcomes

AIM

Develop a novel, physiology-based measurement of duty cycle (Arterial Blood Pressure-Area Duty Cycle [ABP-ADC]) and evaluate the association of ABP-ADC with intra-arrest hemodynamics and patient outcomes.

METHODS

This was a secondary retrospective study of prospectively collected data from the ICU-RESUS trial (NCT02837497). Invasive arterial waveform data were used to derive ABP-ADC. The primary exposure was ABP-ADC group (<30%; 30-35%; >35%). The primary outcome was systolic blood pressure (sBP). Secondary outcomes included intra-arrest physiologic goals, CPR quality targets, and patient outcomes. In an exploratory analysis, adjusted splines and receiver operating characteristic (ROC) curves were used to determine an optimal ABP-ADC associated with improved hemodynamics and outcomes using a multivariable model.

RESULTS

Of 1129 CPR events, 273 had evaluable arterial waveform data. Mean age is 2.9 years + 4.9 months. Mean ABP-ADC was 32.5% + 5.0%. In univariable analysis, higher ABP-ADC was associated with lower sBP (p < 0.01) and failing to achieve sBP targets (p < 0.01). Other intra-arrest physiologic parameters, quality metrics, and patient outcomes were similar across ABP-ADC groups. Using spline/ROC analysis and clinical judgement, the optimal ABP-ADC cut point was set at 33%. On multivariable analysis, sBP was significantly higher (point estimate 13.18 mmHg, CI95 5.30-21.07, p < 0.01) among patients with ABP-ADC < 33%. Other intra-arrest physiologic and patient outcomes were similar.

CONCLUSIONS

In this multicenter cohort, a lower ABP-ADC was associated with higher sBPs during CPR. Although ABP-ADC was not associated with outcomes, further studies are needed to define the interactions between CPR mechanics and intra arrest patient physiology.

A Template for Translational Bioinformatics: Facilitating Multimodal Data Analyses in Preclinical Models of Neurological Injury

Background

Pediatric neurological injury and disease is a critical public health issue due to increasing rates of survival from primary injuries (e.g., cardiac arrest, traumatic brain injury) and a lack of monitoring technologies and therapeutics for the treatment of secondary neurological injury. Translational, preclinical research facilitates the development of solutions to address this growing issue but is hindered by a lack of available data frameworks and standards for the management, processing, and analysis of multimodal data sets.

Methods

Here, we present a generalizable data framework that was implemented for large animal research at the Children's Hospital of Philadelphia to address this technological gap. The presented framework culminates in an interactive dashboard for exploratory analysis and filtered data set download.

Results

Compared with existing clinical and preclinical data management solutions, the presented framework accommodates heterogeneous data types (single measure, repeated measures, time series, and imaging), integrates data sets across various experimental models, and facilitates dynamic visualization of integrated data sets. We present a use case of this framework for predictive model development for intra-arrest prediction of cardiopulmonary resuscitation outcome.

Conclusions

The described preclinical data framework may serve as a template to aid in data management efforts in other translational research labs that generate heterogeneous data sets and require a dynamic platform that can easily evolve alongside their research.

Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study

AIMS

The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes.

DESIGN

A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes.

SETTING

Hospitals reporting to the American Heart Association's Get With The Guidelines®- Resuscitation registry (2007-2021).

PATIENTS

Children with index IHCA with an invasive airway or arterial line at the time of arrest.

RESULTS

Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03).

CONCLUSIONS

Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.

Pediatric in-hospital cardiac arrest: Respiratory failure characteristics and association with outcomes

AIMS

To characterize respiratory failure prior to pediatric in-hospital cardiac arrest (IHCA) and to associate pre-arrest respiratory failure characteristics with survival outcomes.

METHODS

This is a single-center, retrospective cohort study from a prospectively identified cohort of children <18 years in intensive care units (ICUs) who received cardiopulmonary resuscitation (CPR) for ≥1 minute between January 1, 2017 and June 30, 2021, and were receiving invasive mechanical ventilation (IMV) in the hour prior to IHCA. Patient characteristics, ventilatory support and gas exchange immediately pre-arrest were described and their association with the return of spontaneous circulation (ROSC) was measured.

RESULTS

In the 187 events among 154 individual patients, the median age was 0.9 [0.2, 2.4] years, and CPR duration was 7.5 [3, 29] minutes. Respiratory failure was acute prior to 106/187 (56.7%) events, and the primary indication for IMV was respiratory in nature in 107/187 (57.2%) events. Immediately pre-arrest, the median positive end-expiratory pressure was 8 [5, 10] cmH2O; mean airway pressure was 13 [10,18] cmH2O; peak inspiratory pressure was 28 [24, 35] cmH2O; and fraction of inhaled oxygen (FiO2) was 0.40 [0.25, 0.80]. Pre-arrest FiO2 was lower in patients with ROSC vs. without ROSC (0.30 vs. 0.99; p < 0.001). Patients without ROSC had greater severity of pre-arrest oxygenation failure (p < 0.001) as defined by oxygenation index, oxygen saturation index, P/F ratio or S/F ratio.

CONCLUSIONS

There was substantial heterogeneity in respiratory failure characteristics and ventilatory requirements pre-arrest. Higher pre-arrest oxygen requirement and greater degree of oxygenation failure were associated with worse survival outcomes.

Arterial Blood Gas Analysis for Survival Prediction in Pediatric Patients with Out-of-Hospital Cardiac Arrest

Arterial blood gas analysis (ABGA) is one of the few tests performed during cardiopulmonary resuscitation (CPR). There have been some studies on the prediction of survival outcomes in adult out-of-hospital cardiac arrest (OHCA) patients during CPR using ABGA results. However, in pediatric OHCA patients, the prognosis of survival outcome based on ABGA results during CPR remains unclear. We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a multicenter OHCA registry of Republic of Korea. We analyzed 108 pediatric (age < 19 years) OHCA patients between October 2015 and June 2022. Using multivariable logistic regression, an adjusted odds ratio (aOR) was obtained to validate the ABGA results of survival to hospital admission and survival to discharge. The variables associated with survival to hospital admission were non-comorbidities (aOR 3.03, 95% confidence interval (CI) 1.22-7.53, p = 0.017) and PaO₂ > 45.750 mmHg (aOR 2.69, 95% CI 1.13-6.42, p = 0.026). There was no variable that was statistically significant association with survival to discharge. PaO₂ > 47.750 mmHg and non-comorbidities may serve as an independent prognostic factor for survival to hospital admission in pediatric OHCA patients. However, the number of cases analyzed in our study was relatively small, and there have been few studies investigating the association between ABGA results during CPR and the survival outcome of pediatric OHCA patients. Therefore, further large-scale studies are needed.

Cardiopulmonary Resuscitation During Simulated Pediatric Interhospital Transport: Lessons Learned From Implementation of an Institutional Curriculum

INTRODUCTION

Little is known about cardiopulmonary resuscitation (CPR) quality during pediatric interhospital transport; hence, our aim was to investigate its feasibility.

METHODS

After implementing an institutional education curriculum on pediatric resuscitation during ambulance transport, we conducted a 4-year prospective observational study involving simulation events. Simulated scenarios were (1) interhospital transport of a child retrieved in cardiac arrest (Sim1) and (2) unanticipated cardiac arrest of a child during transport (Sim2). Cardiopulmonary resuscitation data were collected via Zoll RSeries defibrillators. Performance was evaluated using age-appropriate American Heart Association (AHA) Guidelines. Video recordings were reviewed for qualitative thematic analysis.

RESULTS

Twenty-six simulations were included: 16 Sim1 [mannequins: Laerdal SimMan 3G (n = 13); Gaumard 5-year-old HAL (n = 3)] and 10 Sim2 [Gaumard 1-year-old HAL (n = 8); Laerdal SimBaby (n = 2)]. Median (IQR) CPR duration was 18 minutes 23 seconds (14-22 minutes), chest compression rate was 112 per minute (106-118), and fraction (CCF) was 1 (0.9-1). Five hundred eight 60-second resuscitation epochs were evaluated (Sim1: 356; Sim2: 152); 73% were AHA compliant for rate and 87.8% for CCF. Twenty-four minutes (4.7%) had pauses more than 10 seconds. One hundred fifty seven Sim1 epochs (44.1%) met criteria for excellent CPR (AHA-compliant for rate, depth, and CCF). Rates of excellent CPR were higher for learner groups with increased simulation and transport experience (59.1% vs. 35.3%, P < 0.001). Thematic analysis identified performance-enhancing strategies, stemming from anticipating challenges, planning solutions, and ensuring team's shared mental model.

CONCLUSIONS

High-quality CPR may be achievable during pediatric interhospital transport. Certain transport-specific strategies may enhance resuscitation quality. Learners' performance improved with simulation and transport experience, highlighting ongoing education's role.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, 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, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

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.