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O'Halloran AJ, Reeder RW, Berg RA, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kienzle MF, Kilbaugh TJ, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Topjian AA, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Morgan RW. Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study. Crit Care 2024; 28:242. [PMID: 39010134 PMCID: PMC11251231 DOI: 10.1186/s13054-024-05018-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Half of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness. METHODS Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016-March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status. RESULTS Of 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001). CONCLUSIONS In this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.
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Affiliation(s)
- Amanda J O'Halloran
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, D.C., DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Martha F Kienzle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, D.C., DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, D.C., DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, D.C., DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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O’Halloran A, Morgan RW, Kennedy K, Berg RA, Gathers CA, Naim MY, Nadkarni V, Reeder R, Topjian A, Wolfe H, Kleinman M, Chan PS, Sutton RM. Characteristics of Pediatric In-Hospital Cardiac Arrests and Resuscitation Duration. JAMA Netw Open 2024; 7:e2424670. [PMID: 39078626 PMCID: PMC11289702 DOI: 10.1001/jamanetworkopen.2024.24670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/30/2024] [Indexed: 07/31/2024] Open
Abstract
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.
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Affiliation(s)
- Amanda O’Halloran
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Kevin Kennedy
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Cody-Aaron Gathers
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Maryam Y. Naim
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Monica Kleinman
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
| | - Paul S. Chan
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
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Shepard LN, Mehta S, Graham K, Kienzle M, O'Halloran A, Yehya N, Morgan RW, Keim GP. Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis. Crit Care Explor 2024; 6:e1088. [PMID: 38747691 PMCID: PMC11098256 DOI: 10.1097/cce.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
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.
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Affiliation(s)
- Lindsay N Shepard
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sanjiv Mehta
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Martha Kienzle
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amanda O'Halloran
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Garrett P Keim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Zinna SS, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Cooper KK, Michael Dean J, Wesley Diddle J, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Hehir DA, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis. Resuscitation 2024; 194:110068. [PMID: 38052273 PMCID: PMC10843614 DOI: 10.1016/j.resuscitation.2023.110068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
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.
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Affiliation(s)
- Shairbanu S Zinna
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
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Chan B, Sieg S, Singh Y. Unveiling pseudo-pulseless electrical activity (pseudo-PEA) in ultrasound-integrated infant resuscitation. Eur J Pediatr 2023; 182:5285-5291. [PMID: 37725211 PMCID: PMC10746595 DOI: 10.1007/s00431-023-05199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
Point-of-care ultrasound (POCUS) holds immense potential to manage critically deteriorating infants within the neonatal intensive care unit (NICU) and is increasingly used in neonatal clinical practice worldwide. Recent ultrasound-based protocols such as the Sonographic Assessment of liFe-threatening Emergencies-Revised (SAFE-R) and Crashing Neonate Protocol (CNP) offer step-by-step guidance for diagnosing and addressing reversible causes of cardiorespiratory collapse. Traditionally, pulseless electrical activity (PEA) has been diagnosed solely based on absent pulses on clinical examination, disregarding myocardial activity. However, integrating POCUS into resuscitation unveils the concept of pseudo-PEA, where cardiac motion activity is observed visually on the ultrasound but fails to generate a detectable pulse due to inadequate cardiac output. Paradoxically, existing neonatal resuscitation protocols lack directives for identifying and effectively leveraging pseudo-PEA insights in infants, limiting their potential to enhance outcomes. Pseudo-PEA is extensively described in adult literature owing to routine POCUS use in resuscitation. This review article comprehensively evaluates the adult pseudo-PEA literature to glean insights adaptable to neonatal care. Additionally, we propose a simple strategy to integrate POCUS during neonatal resuscitation, especially in infants who do not respond to routine measures. CONCLUSION Pseudo-PDA is a newly recognized diagnosis in infants with the use of POCUS during resuscitation. This article highlights the importance of cross-disciplinary learning in tackling emerging challenges within neonatal medicine. WHAT IS KNOWN • Point-of-Care ultrasound (POCUS) benefits adult cardiac arrest management, particularly in distinguishing true Pulseless Electrical Activity (PEA) from pseudo-PEA. • Pseudo-PEA is when myocardial motion can be seen on ultrasound but fails to generate palpable pulses or sustain circulation despite evident cardiac electrical activity. WHAT IS NEW • Discuss recognition and management of pseudo-PEA in infants. • A proposed algorithm to integrate POCUS into active neonatal cardiopulmonary resuscitation (CPR) procedures.
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Affiliation(s)
- Belinda Chan
- Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City, UT, 84108, USA
- Department of Radiology and Imaging Science, University of Utah, Salt Lake City, UT, 84108, USA
| | - Susan Sieg
- Intermountain Healthcare, Salt Lake City, UT, 84108, USA
| | - Yogen Singh
- Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, 11175 Coleman Pavilion, Campus Street, Loma Linda, CA, 92354, USA.
- Department of Pediatrics, Division of Neonatology, University of Southern California, Los Angeles, CA, 90089, USA.
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Hanna A, Crowe RP, Fishe JN. Pediatric Bradycardia Is Undertreated in the Prehospital Setting: A Retrospective Multi-Agency Analysis. PREHOSP EMERG CARE 2023; 27:101-106. [PMID: 34913820 DOI: 10.1080/10903127.2021.2018075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Bradycardia is the most common terminal cardiac electrical activity in children, and early recognition and treatment is necessary to avoid cardiac arrest. Interventions such as oxygen, chest compressions, epinephrine, and atropine recommended by American Heart Association (AHA) Pediatric Advanced Life support (PALS) guidelines have been shown to improve outcomes (including higher survival rates) for inpatient pediatric patients with bradycardia. However, little is known about the epidemiology of pediatric prehospital bradycardia. We sought to investigate the incidence and management of pediatric bradycardia in the prehospital setting by emergency medical services (EMS). METHODS This was a retrospective study of 911 scene response prehospital encounters for patients ages 0-18 years in 2019 from the United States ESO Research Data Collaborative. We defined age-based bradycardia per the 2015 AHA PALS guidelines. We performed general descriptive statistics and a univariate analysis examining any PALS-recommended interventions in the presence of altered mental status, hypotension for age, and a first heart rate less than 60. RESULTS Of 7,422,710 encounters in the 2019 ESO Data Collaborative, 1,209 patients met inclusion criteria. Most (58.5%) were male, and the median age was 2 years (interquartile range 0-13 years). One-quarter (24.7%) of patients received fluids, and bag-valve mask ventilation was the most common airway intervention (12.1% of patients). Receipt of any PALS-recommended interventions was associated with age-adjusted hypotension (odds ratio (OR) 4.0, 95% confidence interval (CI) 3.9-5.4) and altered mental status (OR 15.5, 95% CI 10.7-22.3), but not a first heart rate less than 60 bpm (OR 0.9, 95% CI 0.6-1.1). CONCLUSIONS To our knowledge, this study is the first to examine the incidence and management of prehospital pediatric bradycardia. Incidence was rare, but adherence to PALS guidelines was variable. Further research and education are needed to ensure proper prehospital treatment of pediatric bradycardia.
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Affiliation(s)
- Andrew Hanna
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | | | - Jennifer N Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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O'Halloran AJ, Grossestreuer AV, Balaji L, Ross CE, Holmberg MJ, Donnino MW, Kleinman ME. Characteristics and Outcomes of Cardiac Arrest in Adult Patients Admitted to Pediatric Services: A Descriptive Analysis of the American Heart Association's Get With The Guidelines-Resuscitation Data. Pediatr Crit Care Med 2023; 24:17-24. [PMID: 36516345 PMCID: PMC9812904 DOI: 10.1097/pcc.0000000000003104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services. DESIGN Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old). SETTING Hospitals contributing to the Get With The Guidelines-Resuscitation registry. PATIENTS Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge). CONCLUSIONS In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.
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Affiliation(s)
- Amanda J O'Halloran
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Lakshman Balaji
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Monica E Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Chapman JD, Geneslaw AS, Babineau J, Sen AI. Improving Ventilation Rates During Pediatric Cardiopulmonary Resuscitation. Pediatrics 2022; 150:188943. [PMID: 36000325 DOI: 10.1542/peds.2021-053030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Excessive ventilation at rates of 30 breaths per minute (bpm) or more during cardiopulmonary resuscitation (CPR) decreases venous return and coronary perfusion pressure, leading to lower survival rates in animal models. A review of our institution's pediatric CPR data revealed that patients frequently received excessive ventilation. METHODS We designed a multifaceted quality improvement program to decrease the incidence of clinically significant hyperventilation (≥30 bpm) during pediatric CPR. The program consisted of provider education, CPR ventilation tools (ventilation reminder cards, ventilation metronome), and individual CPR team member feedback. CPR events were reviewed pre- and postintervention. The first 10 minutes of each CPR event were divided into 20 second epochs, and the ventilation rate in each epoch was measured via end-tidal carbon dioxide waveform. Individual epochs were classified as within the target ventilation range (<30 bpm) or clinically significant hyperventilation (≥30 bpm). The proportion of epochs with clinically significant hyperventilation, as well as median ventilation rates, were analyzed in the pre- and postintervention periods. RESULTS In the preintervention period (37 events, 699 epochs), 51% of CPR epochs had ventilation rates ≥30 bpm. In the postintervention period (24 events, 426 epochs), the proportion of CPR epochs with clinically significant hyperventilation decreased to 29% (P < .001). Median respiratory rates decreased from 30 bpm (interquartile range 21-36) preintervention to 21 bpm (interquartile range 12-30) postintervention (P < .001). CONCLUSIONS A quality improvement initiative grounded in improved provider education, CPR team member feedback, and tools focused on CPR ventilation rates was effective at reducing rates of clinically significant hyperventilation during pediatric CPR.
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Affiliation(s)
- Jennifer D Chapman
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Andrew S Geneslaw
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - John Babineau
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Anita I Sen
- Department of Pediatrics, Columbia University Medical Center, New York, New York
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Best K, Wyckoff MH, Huang R, Sandford E, Ali N. Pulseless electrical activity and asystolic cardiac arrest in infants: identifying factors that influence outcomes. J Perinatol 2022; 42:574-579. [PMID: 35177792 DOI: 10.1038/s41372-022-01349-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is limited information on pulseless electrical activity (PEA)/asystolic cardiac arrest (CA) in the infant population. The aim is to describe the incidence and factors associated with outcomes in infants with PEA/asystolic CA. METHODS Single-center retrospective chart review study of infants less than one year of age who suffer in-hospital PEA/asystolic CA from January 1 2011 to June 30 2019. The primary outcome was the return of spontaneous circulation. The secondary outcome was survival to discharge. RESULTS CA occurred in 148 infants and PEA/asystolic was found in 38 (26%). Of those 29 (76%) achieved ROSC, and 12 (32%) survived to discharge. Infants on inotrope support or receiving longer duration of chest compressions and epinephrine had increase mortality. All infants with respiratory etiology of arrest survived to hospital discharge. CONCLUSION PEA/asystolic CAs are uncommon. Poor prognostic indicators include the need for pre-arrest inotrope support and increased duration of chest compressions.
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Affiliation(s)
- Kathryn Best
- UT Southwestern Medical Center Department of Pediatrics Division of Critical Care Medicine, Dallas, TX, USA
| | - Myra H Wyckoff
- UT Southwestern Medical Center Department of Pediatrics Division of Neonatal-Perinatal Medicine, Dallas, TX, USA
| | - Rong Huang
- Children's Medical Center Dallas Department of Biostatistics, Dallas, TX, USA
| | - Ethan Sandford
- UT Southwestern Medical Center Department of Pediatrics Division of Critical Care Medicine, Dallas, TX, USA
| | - Noorjahan Ali
- UT Southwestern Medical Center Department of Pediatrics Division of Neonatal-Perinatal Medicine, Dallas, TX, USA.
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10
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Pulmonary hypertension among children with in-hospital cardiac arrest: A multicenter study. Resuscitation 2021; 168:52-57. [PMID: 34536558 DOI: 10.1016/j.resuscitation.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/20/2022]
Abstract
AIMS To determine the prevalence of pulmonary hypertension (PH) among children with in-hospital cardiac arrest (IHCA) and its association with survival. METHODS Children (<18 years) admitted to ICUs participating in the Virtual Pediatric Systems multicenter registry between January 2011 and December 2017 who had an IHCA during their hospitalization were included. Patients were classified by whether they had a documented diagnosis of PH at the time of IHCA. Clinical characteristics were compared between patients with and without PH. After propensity score matching, conditional logistic regression within the matched cohort determined the association between PH and survival to hospital discharge. RESULTS Of 18,575 children with IHCA during the study period, 1,590 (8.6%) had a pre-arrest diagnosis of PH. Patients with PH were more likely to be 29 days to 2 years of age, female, Black/African American, and American Indian/Alaskan Native, and to be treated in a cardiac ICU or mixed PICU/cardiac ICU. At ICU admission, PH patients had a lower probability of death as determined by the Pediatric Index of Mortality 2 (PIM-2) score. Patients with PH were more likely to be receiving inhaled nitric oxide (13.0% vs. 2.1%; p < 0.001). Propensity score matching successfully matched 1,302 PH patients with 3,604 non-PH patients. Patients with PH were less likely to survive to hospital discharge (aOR 0.83; 95% CI: 0.72-0.95; p = 0.01) than non-PH patients. CONCLUSIONS In this large multicenter study, 8.6% of children with IHCA had pre-existing documented PH. These children were less likely to survive to hospital discharge than those without PH.
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11
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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12
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Survival and Hemodynamics During Pediatric Cardiopulmonary Resuscitation for Bradycardia and Poor Perfusion Versus Pulseless Cardiac Arrest. Crit Care Med 2021; 48:881-889. [PMID: 32301844 DOI: 10.1097/ccm.0000000000004308] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to compare survival outcomes and intra-arrest arterial blood pressures between children receiving cardiopulmonary resuscitation for bradycardia and poor perfusion and those with pulseless cardiac arrests. DESIGN Prospective, multicenter observational study. SETTING PICUs and cardiac ICUs of the Collaborative Pediatric Critical Care Research Network. PATIENTS Children (< 19 yr old) who received greater than or equal to 1 minute of cardiopulmonary resuscitation with invasive arterial blood pressure monitoring in place. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 164 patients, 96 (59%) had bradycardia and poor perfusion as the initial cardiopulmonary resuscitation rhythm. Compared to those with initial pulseless rhythms, these children were younger (0.4 vs 1.4 yr; p = 0.005) and more likely to have a respiratory etiology of arrest (p < 0.001). Children with bradycardia and poor perfusion were more likely to survive to hospital discharge (adjusted odds ratio, 2.31; 95% CI, 1.10-4.83; p = 0.025) and survive with favorable neurologic outcome (adjusted odds ratio, 2.21; 95% CI, 1.04-4.67; p = 0.036). There were no differences in diastolic or systolic blood pressures or event survival (return of spontaneous circulation or return of circulation via extracorporeal cardiopulmonary resuscitation). Among patients with bradycardia and poor perfusion, 49 of 96 (51%) had subsequent pulselessness during the cardiopulmonary resuscitation event. During cardiopulmonary resuscitation, these patients had lower diastolic blood pressure (point estimate, -6.68 mm Hg [-10.92 to -2.44 mm Hg]; p = 0.003) and systolic blood pressure (point estimate, -12.36 mm Hg [-23.52 to -1.21 mm Hg]; p = 0.032) and lower rates of return of spontaneous circulation (26/49 vs 42/47; p < 0.001) than those who were never pulseless. CONCLUSIONS Most children receiving cardiopulmonary resuscitation in ICUs had an initial rhythm of bradycardia and poor perfusion. They were more likely to survive to hospital discharge and survive with favorable neurologic outcomes than patients with pulseless arrests, although there were no differences in immediate event outcomes or intra-arrest hemodynamics. Patients who progressed to pulselessness after cardiopulmonary resuscitation initiation had lower intra-arrest hemodynamics and worse event outcomes than those who were never pulseless.
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13
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Morgan RW, Kirschen MP, Kilbaugh TJ, Sutton RM, Topjian AA. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr 2021; 175:293-302. [PMID: 33226408 PMCID: PMC8787313 DOI: 10.1001/jamapediatrics.2020.5039] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR). OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes. CONCLUSIONS AND RELEVANCE Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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15
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Wagner M, Cheung PY, Yaskina M, Lee TF, Vieth VA, O'Reilly M, Schmölzer GM. Return of Spontaneous Circulation Depends on Cardiac Rhythm During Neonatal Cardiac Arrest in Asphyxiated Newborn Animals. Front Pediatr 2021; 9:641132. [PMID: 33643979 PMCID: PMC7907180 DOI: 10.3389/fped.2021.641132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/25/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: Pulseless electrical activity (PEA) occurs in asphyxiated newborn piglets and infants. We aimed to examine whether different cardiac rhythms (asystole, bradycardia, PEA) affects the resuscitation outcomes during continuous chest compressions (CC) during sustained inflations (CC+SI). Design: This study is a secondary analysis of four previous randomized controlled animal trials that compared CC+SI with different CC rate (90 or 120/min), SI duration (20 or 60 s), peak inflation pressure (10, 20, or 30 cmH2O), and oxygen concentration (18, 21, or 100%). Setting and Subjects: Sixty-six newborn mixed breed piglets (1-3 days of age, weight 1.7-2.4 kg) were obtained on the day of experimentation from the University Swine Research Technology Center. Interventions: In all four studies, piglets were randomized into intervention or sham. Piglets randomized to "intervention" underwent both hypoxia and asphyxia, whereas, piglets randomized to "sham" received the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia. Measurements: To compare differences in asphyxiation time, time to return of spontaneous circulation (ROSC), hemodynamics, and survival rate in newborn piglets with asystole, bradycardia or PEA. Main Results: Piglets with PEA (n = 29) and asystole (n = 13) had a significantly longer asphyxiation time and time to ROSC vs. bradycardia (n = 24). Survival rates were similar between all groups. Compared to their baseline, mean arterial pressure and carotid blood flow were significantly lower 4 h after resuscitation in all groups, while being significantly higher in the bradycardia group. Conclusion: This study indicates that cardiac rhythm before resuscitation influences the time to ROSC and hemodynamic recovery after ROSC.
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Affiliation(s)
- Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.,Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Maryna Yaskina
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Vanessa A Vieth
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Megan O'Reilly
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Division of Neonatology, Department of Pediatrics, Medical University Graz, Graz, Austria
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16
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A120-A155. [PMID: 33098916 PMCID: PMC7576321 DOI: 10.1016/j.resuscitation.2020.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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17
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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18
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S140-S184. [PMID: 33084393 DOI: 10.1161/cir.0000000000000894] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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19
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Abstract
OBJECTIVES The objective of this study was to associate ventilation rates during in-hospital cardiopulmonary resuscitation with 1) arterial blood pressure during cardiopulmonary resuscitation and 2) survival outcomes. DESIGN Prospective, multicenter observational study. SETTING Pediatric and pediatric cardiac ICUs of the Collaborative Pediatric Critical Care Research Network. PATIENTS Intubated children (≥ 37 wk gestation and < 19 yr old) who received at least 1 minute of cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood pressure and ventilation rate (breaths/min) were manually extracted from arterial line and capnogram waveforms. Guideline rate was defined as 10 ± 2 breaths/min; high ventilation rate as greater than or equal to 30 breaths/min in children less than 1 year old, and greater than or equal to 25 breaths/min in older children. The primary outcome was survival to hospital discharge. Regression models using Firth penalized likelihood assessed the association between ventilation rates and outcomes. Ventilation rates were available for 52 events (47 patients). More than half of patients (30/47; 64%) were less than 1 year old. Eighteen patients (38%) survived to discharge. Median event-level average ventilation rate was 29.8 breaths/min (interquartile range, 23.8-35.7). No event-level average ventilation rate was within guidelines; 30 events (58%) had high ventilation rates. The only significant association between ventilation rate and arterial blood pressure occurred in children 1 year old or older and was present for systolic blood pressure only (-17.8 mm Hg/10 breaths/min; 95% CI, -27.6 to -8.1; p < 0.01). High ventilation rates were associated with a higher odds of survival to discharge (odds ratio, 4.73; p = 0.029). This association was stable after individually controlling for location (adjusted odds ratio, 5.97; p = 0.022), initial rhythm (adjusted odds ratio, 3.87; p = 0.066), and time of day (adjusted odds ratio, 4.12; p = 0.049). CONCLUSIONS In this multicenter cohort, ventilation rates exceeding guidelines were common. Among the range of rates delivered, higher rates were associated with improved survival to hospital discharge.
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Nguyen D, Kritek PA, Greco SA, Prutkin JM. Bradycardia at the onset of pulseless electrical activity arrests in hospitalized patients is associated with improved survival to discharge. Heliyon 2020; 6:e03491. [PMID: 32140601 PMCID: PMC7049649 DOI: 10.1016/j.heliyon.2020.e03491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 11/29/2022] Open
Abstract
Background Recent studies have suggested that the incidence of in-hospital pulseless electrical activity (PEA) arrests is increasing. Bradycardia in patients with in-hospital PEA is common but it is unknown if it is associated with respiratory arrest or patient outcomes. Objective To determine risk factors and outcomes associated with bradycardic-PEA arrests, and relationship between bradycardia and respiratory arrest. Methods This was a retrospective cohort study of all inpatient cardiac arrests at an academic medical center over a four-year period. Patient demographics, comorbidities, vital signs, arrest event data, and outcomes were abstracted from the medical record. PEA arrest was defined as a non-shockable rhythm with loss of pulse requiring cardiopulmonary resuscitation and having organized electrocardiographic activity. Bradycardia was classified as a HR < 60 bpm at the time of pulse loss. The primary outcomes were survival of arrest and survival to hospital discharge. Results Between July 2013 and August 2017, there were 176 in-hospital patients with PEA arrests. While 105 (59.7%) survived the arrest, only 38 (21.6%) survived to discharge. A total of 66 (37.5%) were bradycardic-PEA arrests. Patients with bradycardic PEA arrests were no more likely to have their arrest precipitated by respiratory failure than non-bradycardic PEA patients (36.4% vs 27.3%, P = 0.24), but patients with non-bradycardic PEA arrests were more likely to have a CIED than non-bradycardic PEA patients (14.5% vs 3.0%, P = 0.02). On multivariate analysis, bradycardic PEA was associated with improved survival to hospital discharge (OR = 3.31, 95% CI: 1.41–7.79, p = 0.006), but not survival of arrest (OR 1.45, 95% CI: 0.68–3.09, p = 0.34). Respiratory arrest was an independent predictor of survival of code (OR 2.62, 95% CI: 1.36–5.47, P = 0.01) and to hospital discharge (OR 3.47, 95% CI: 1.35–8.91, P = 0.01). Other predictors of survival to discharge include history of coronary artery disease, and non-use of epinephrine, atropine, and sodium bicarbonate. Conclusion In a retrospective study of hospitalized patients in the intensive care unit and non-intensive care, bradycardia at the time of PEA cardiac arrest was associated with improved survival to hospital discharge but not survival of arrest. Respiratory arrest was an independent predictor of survival, but there was no association between respiratory arrest and bradycardic PEA arrest.
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Affiliation(s)
- Dan Nguyen
- University of Washington, Internal Medicine Residency, USA
| | - Patricia A Kritek
- University of Washington, Division of Pulmonary, Critical Care and Sleep Medicine, USA
| | - Sheryl A Greco
- University of Washington, Divisions of Critical Care and Cardiology, Patient Care Services, USA
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21
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Molyneux EM. Cardiopulmonary resuscitation in poorly resourced settings: better to pre-empt than to wait until it is too late. Paediatr Int Child Health 2020; 40:1-6. [PMID: 31116094 DOI: 10.1080/20469047.2019.1616150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- E M Molyneux
- College of Medicine, University of Malawi, Blantyre, Malawi,
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22
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Cardiopulmonary Resuscitation in the Pediatric Cardiac Catheterization Laboratory: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry. Pediatr Crit Care Med 2019; 20:1040-1047. [PMID: 31232852 DOI: 10.1097/pcc.0000000000002038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Hospitalized children with underlying heart disease are at high risk for cardiac arrest, particularly when they undergo invasive catheterization procedures for diagnostic and therapeutic interventions. Outcomes for children experiencing cardiac arrest in the cardiac catheterization laboratory remain under-reported with few studies reporting survival beyond the catheterization laboratory. We aim to describe survival outcomes after cardiac arrest in the cardiac catheterization laboratory while identifying risk factors associated with hospital mortality after these events. DESIGN Retrospective observational study of data from a multicenter cardiac arrest registry from November 2005 to November 2016. Cardiac arrest in the cardiac catheterization laboratory was defined as the need for chest compressions greater than or equal to 1 minute in the cardiac catheterization laboratory. Primary outcome was survival to discharge. Variables analyzed using generalized estimating equations for association with survival included age, illness category (surgical cardiac, medical cardiac), preexisting conditions, pharmacologic interventions, and event duration. SETTING American Heart Association's Get With the Guidelines-Resuscitation registry of in-hospital cardiac arrest. PATIENTS Consecutive patients less than 18 years old experiencing an index (i.e., first) cardiac arrest event reported to the Get With the Guidelines-Resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 203 patients met definition of index cardiac arrest in the cardiac catheterization laboratory composed primarily of surgical and medical cardiac patients (54% and 41%, respectively). Children less than 1 year old comprised the majority of patients, 58% (117/203). Overall survival to hospital discharge was 69% (141/203). No differences in survival were observed between surgical and medical cardiac patients (p = 0.15). The majority of deaths (69%, 43/62) occurred in patients less than 1 year old. Bradycardia (with pulse) followed by pulseless electrical activity/asystole were the most common first documented rhythms observed (50% and 27%, respectively). Preexisting metabolic/electrolyte abnormalities (p = 0.02), need for vasoactive infusions (p = 0.03) prior to arrest, and use of calcium products (p = 0.005) were found to be significantly associated with lower rates of survival to discharge on multivariable regression. CONCLUSIONS The majority of children experiencing cardiac arrest in the cardiac catheterization laboratory in this large multicenter registry analysis survived to hospital discharge, with no observable difference in outcomes between surgical and medical cardiac patients. Future investigations that focus on stratifying medical complexity in addition to procedural characteristics at the time of catheterization are needed to better identify risks for mortality after cardiac arrest in the cardiac catheterization laboratory.
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Agrawal V, Lakshminrusimha S, Chandrasekharan P. Chest Compressions for Bradycardia during Neonatal Resuscitation-Do We Have Evidence? CHILDREN-BASEL 2019; 6:children6110119. [PMID: 31671867 PMCID: PMC6915497 DOI: 10.3390/children6110119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 02/06/2023]
Abstract
The International Liaison Committee on Resuscitation (ILCOR) recommends the initiation of chest compressions (CC) during neonatal resuscitation after 30 s of effective ventilation if the infant remains bradycardic (defined as a heart rate less than 60 bpm). The CC are performed during bradycardia to optimize organ perfusion, especially to the heart and brain. Among adults and children undergoing cardiopulmonary resuscitation (CPR), CC is indicated only for pulselessness or poor perfusion. Neonates have a healthy heart that attempts to preserve coronary and cerebral perfusion during bradycardia secondary to asphyxia. Ventilation of the lungs is the key step during neonatal resuscitation, improving gas exchange and enhancing cerebral and cardiac blood flow by changes in intrathoracic pressure. Compressing the chest 90 times per minute without synchrony with innate cardiac activity during neonatal bradycardia is not based on evidence and could potentially be harmful. Although there are no studies evaluating outcomes in neonates, a recent pediatric study in a hospital setting showed that when CC were initiated during pulseless bradycardia, a third of the patients went into complete arrest, with poor survival at discharge. Ventilation-only protocols such as helping babies breathe are effective in reducing mortality and stillbirths in low-resource settings. In a situation of complete cardiac arrest, CC reinitiates pulmonary flow and supports gas exchange. However, the benefit/harm of performing asynchronous CC during bradycardia as part of neonatal resuscitation remains unknown.
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Affiliation(s)
- Vikash Agrawal
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, NY 14260, USA.
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis, Davis, CA 95616, USA.
| | - Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Buffalo, NY 14260, USA.
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24
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Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK, Donnino MW, Andersen LW. Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States. Circulation 2019; 140:1398-1408. [PMID: 31542952 DOI: 10.1161/circulationaha.119.041667] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac arrest in hospitalized children is associated with poor outcomes, but no contemporary study has reported whether the trends in survival have changed over time. In this study, we examined temporal trends in survival for pediatric patients with an in-hospital pulseless cardiac arrest and pediatric patients with a nonpulseless cardiopulmonary resuscitation event from 2000 to 2018. METHODS This was an observational study of hospitalized pediatric patients (≤18 years of age) who received cardiopulmonary resuscitation from January 2000 to December 2018 and were included in the Get With The Guidelines-Resuscitation registry, a United States-based in-hospital cardiac arrest registry. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (binary outcomes). Generalized estimation equations were used to obtain unadjusted trends in outcomes over time. Separate analyses were performed for patients with a pulseless cardiac arrest and patients with a nonpulseless event (bradycardia with poor perfusion) requiring cardiopulmonary resuscitation. A subgroup analysis was conducted for shockable versus nonshockable initial rhythms in pulseless events. RESULTS A total of 7433 patients with a pulseless cardiac arrest and 5751 patients with a nonpulseless event were included for the analyses. For pulseless cardiac arrests, survival was 19% (95% CI, 11%-29%) in 2000 and 38% (95% CI, 34%-43%) in 2018, with an absolute change of 0.67% (95% CI, 0.40%-0.95%; P<0.001) per year, although the increase in survival appeared to stagnate following 2010. Return of spontaneous circulation also increased over time, with an absolute change of 0.83% (95% CI, 0.53%-1.14%; P<0.001) per year. We found no interaction between survival to hospital discharge and the initial rhythm. For nonpulseless events, survival was 57% (95% CI, 39%-75%) in 2000 and 66% (95% CI, 61%-72%) in 2018, with an absolute change of 0.80% (95% CI, 0.32%-1.27%; P=0.001) per year. CONCLUSIONS Survival has improved for pediatric events requiring cardiopulmonary resuscitation in the United States, with a 19% absolute increase in survival for in-hospital pulseless cardiac arrests and a 9% absolute increase in survival for nonpulseless events between 2000 and 2018. However, survival from pulseless cardiac arrests appeared to have reached a plateau following 2010.
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Affiliation(s)
- Mathias J Holmberg
- Department of Emergency Medicine, Horsens Regional Hospital, Horsens, Denmark (M.J.H.).,Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
| | - Sebastian Wiberg
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Cardiology, Copenhagen University Hospital, Denmark (S.W.)
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Division of Medical Critical Care, Department of Pediatrics (C.E.R.), Boston Children's Hospital, Harvard Medical School, MA
| | - Monica Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine (M.K.), Boston Children's Hospital, Harvard Medical School, MA
| | - Anne Kirstine Hoeyer-Nielsen
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Clinical Research, Center for Prehospital and Emergency Research, Aalborg University, Denmark (A.K.H.-N.)
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine (M.W.D.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
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Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J, Grossestreuer AV, Yankama T, Donnino MW, Andersen LW, Chan P, Grossestreuer AV, Moskowitz A, Edelson D, Ornato J, Berg K, Peberdy MA, Churpek M, Kurz M, Starks MA, Girotra S, Perman S, Goldberger Z, Guerguerian AM, Atkins D, Foglia E, Fink E, Lasa JJ, Roberts J, Bembea M, Gaies M, Kleinman M, Gupta P, Sutton R, Sawyer T. Annual Incidence of Adult and Pediatric In-Hospital Cardiac Arrest in the United States. Circ Cardiovasc Qual Outcomes 2019. [DOI: 10.1161/circoutcomes.119.005580] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Previous incidence estimates may no longer reflect the current public health burden of cardiac arrest in hospitalized adult and pediatric patients across the United States. The aim of this study was to estimate the contemporary annual incidence of in-hospital cardiac arrest in adults and children across the United States and to describe trends in incidence between 2008 and 2017.
Methods and Results:
Using the Get With The Guidelines–Resuscitation registry, we developed a negative binomial regression model to estimate the incidence of index pulseless in-hospital cardiac arrest based on hospital-level characteristics. The model was used to predict the number of in-hospital cardiac arrests in all US hospitals, using data from the American Hospital Association Annual Survey. We performed separate analyses for adult (≥18 years) and pediatric (<18 years) cardiac arrests. Additional analyses were performed for recurrent cardiac arrests and pediatric patients requiring cardiopulmonary resuscitation for poor perfusion (nonpulseless events). The average annual incidence of in-hospital cardiac arrest in the United States was estimated at 292 000 (95% prediction interval, 217 600–503 500) adult and 15 200 pediatric cases, of which 7100 (95% prediction interval, 4400–9900) cases were pulseless cardiac arrests and 8100 (95% prediction interval, 4700–11 500) cases were nonpulseless events. The rate of adult cardiac arrests increased over time, while pediatric events remained more stable. When including both index and recurrent in-hospital cardiac arrests, the average annual incidence was estimated at 357 900 (95% prediction interval, 247 100–598 400) adult and 19 900 pediatric cases, of which 8300 (95% prediction interval, 4900–11 200) cases were pulseless cardiac arrests and 11 600 (95% prediction interval, 6400–16 700) cases were nonpulseless events.
Conclusions:
There are ≈292 000 adult in-hospital cardiac arrests and 15 200 pediatric in-hospital events in the United States each year. This study provides contemporary estimates of the public health burden of cardiac arrest among hospitalized patients.
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Affiliation(s)
- Mathias J. Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.J.H., A.V.G., T.Y., M.W.D., L.W.A.)
| | - Catherine E. Ross
- Division of Medicine Critical Care, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, MA (C.E.R.)
| | - Garrett M. Fitzmaurice
- Department of Psychiatry, Harvard Medical School, MA (G.F.)
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (G.F.)
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, MA (G.F.)
| | - Paul S. Chan
- St Luke’s Mid America Heart Institute, the University of Missouri, Kansas City (P.S.C.)
| | - Jordan Duval-Arnould
- Division of Health Sciences Informatics, Department of Anesthesiology and Critical Care Medicine, School of Medicine, The Johns Hopkins University, Baltimore, MD (J.D.-A.)
| | - Anne V. Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.J.H., A.V.G., T.Y., M.W.D., L.W.A.)
| | - Tuyen Yankama
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.J.H., A.V.G., T.Y., M.W.D., L.W.A.)
| | - Michael W. Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.J.H., A.V.G., T.Y., M.W.D., L.W.A.)
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.W.D.)
| | - Lars W. Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (M.J.H., A.V.G., T.Y., M.W.D., L.W.A.)
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Khera R, Tang Y, Girotra S, Nadkarni VM, Link MS, Raymond TT, Guerguerian AM, Berg RA, Chan PS. Pulselessness After Initiation of Cardiopulmonary Resuscitation for Bradycardia in Hospitalized Children. Circulation 2019; 140:370-378. [PMID: 31006260 DOI: 10.1161/circulationaha.118.039048] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is initiated in hospitalized children with bradycardia and poor perfusion. However, their rate of progression to pulseless cardiac arrest despite CPR and the differences in survival compared with initially pulseless arrest are unknown. We examined the prevalence and predictors of survival of children who progress from bradycardia to pulseless in-hospital cardiac arrest despite CPR. METHODS Pediatric patients >30 days and <18 years of age who received CPR at hospitals participating in Get With The Guidelines-Resuscitation during 2000 to 2016 were included. Each CPR event was classified as bradycardia with pulse, bradycardia with subsequent pulselessness, and initial pulseless cardiac arrest. We assessed risk-adjusted rates of survival to hospital discharge using multilevel Poisson regression models. RESULTS Overall, 5592 pediatric patients were treated with CPR, of whom 2799 (50.1%) received CPR for bradycardia with poor perfusion and 2793 (49.9%) for initial pulseless cardiac arrest. Among those with bradycardia, 869 (31.0%, or 15.5% of cohort) became pulseless after a median of 3 minutes of CPR (interquartile range, 1-9 minutes). Rates of survival to discharge were 70.0% (1351 of 1930) for bradycardia with pulse, 30.1% (262 of 869) for bradycardia progressing to pulselessness, and 37.5% (1046 of 2793) for initial pulseless cardiac arrest (P for difference across groups <0.001). Children who became pulseless despite CPR for bradycardia had a 19% lower likelihood (risk ratio, 0.81 [95% CI, 0.70, 0.93]; P=0.004) of surviving to hospital discharge than those who were initially pulseless. Among children who progressed to pulselessness despite CPR for bradycardia, a longer interval between CPR and pulselessness was a predictor of lower survival (reference, <2 minutes; for 2-5 minutes, risk ratio, 0.54 [95% CI, 0.41-0.70]; for >5 minutes, risk ratio, 0.41 [95% CI, 0.32-0.53]). CONCLUSIONS Among hospitalized children in whom CPR is initiated, half have bradycardia with poor perfusion at the initiation of chest compressions, and nearly one-third of these progress to pulseless in-hospital cardiac arrest despite CPR. Survival was significantly lower for children who progress to pulselessness despite CPR compared with those who were initially pulseless. These findings suggest that pediatric patients who lose their pulse despite resuscitation attempts are at particularly high risk and require a renewed focus on postresuscitation care.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., M.S.L.)
| | - Yuanyuan Tang
- Mid-America Heart Institute, Kansas City, MO (Y.T., P.S.C.)
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City (S.G.)
| | - Vinay M Nadkarni
- Children's Hospital of Philadelphia, PA (V.M.N., R.A.B.).,Department of Anesthesiology and Critical Care Medicine and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (V.M.N., R.A.B.)
| | - Mark S Link
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., M.S.L.)
| | - Tia T Raymond
- Division of Pediatric Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX (T.T.R.)
| | | | - Robert A Berg
- Children's Hospital of Philadelphia, PA (V.M.N., R.A.B.).,Department of Anesthesiology and Critical Care Medicine and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia (V.M.N., R.A.B.)
| | - Paul S Chan
- Mid-America Heart Institute, Kansas City, MO (Y.T., P.S.C.).,Division of Cardiology, Department of Internal Medicine, University of Missouri-Kansas City (P.S.C.)
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Nordseth T, Niles DE, Eftestøl T, Sutton RM, Irusta U, Abella BS, Berg RA, Nadkarni VM, Skogvoll E. Rhythm characteristics and patterns of change during cardiopulmonary resuscitation for in-hospital paediatric cardiac arrest. Resuscitation 2019; 135:45-50. [PMID: 30639791 DOI: 10.1016/j.resuscitation.2019.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/05/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
During paediatric cardiopulmonary resuscitation (CPR), patients may transition between pulseless electrical activity (PEA), asystole, ventricular fibrillation/tachycardia (VF/VT), and return of spontaneous circulation (ROSC). The aim of this study was to quantify the dynamic characteristics of this process. METHODS ECG recordings were collected in patients who received CPR at the Children's Hospital of Philadelphia (CHOP) between 2006 and 2013. Transitions between PEA (including bradycardia with poor perfusion), VF/VT, asystole, and ROSC were quantified by applying a multi-state statistical model with competing risks, and by smoothing the Nelson-Aalen estimator of cumulative hazard. RESULTS Seventy-four episodes of cardiac arrest were included. Median age of patients was 15 years [IQR 11-17], 50% were female and 62% had a respiratory aetiology of arrest. Presenting cardiac arrest rhythms were PEA (60%), VF/VT (24%) and asystole (16%). A temporary surge of PEA was observed between 10 and 15 min due to a doubling of the transition rate from ROSC to PEA (i.e. 're-arrests'). The prevalence of sustained ROSC reached an asymptotic value of 30% at 20 min. Simulation suggests that doubling the transition rate from PEA to ROSC and halving the relapse rate might increase the prevalence of sustained ROSC to 50%. CONCLUSION Children and adolescents who received CPR were prone to re-arrest between 10 and 15 min after start of CPR efforts. If the rate of PEA to ROSC transition could be increased and the rate of re-arrests reduced, the overall survival rate may improve.
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Affiliation(s)
- Trond Nordseth
- Department of Emergency Medicine and Prehospital Services, St.Olav Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NO-7491, Trondheim, Norway.
| | - Dana E Niles
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Trygve Eftestøl
- Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Unai Irusta
- Department of Communications Engineering, University of the Basque Country, Bilbao, Spain
| | - Benjamin S Abella
- Center for Resuscitation Science, University of Pennsylvania, Philadelphia, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, NO-7491, Trondheim, Norway; Department of Anaesthesia and Intensive Care Medicine, St.Olav Hospital, Trondheim, Norway
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Assessing the efficacy of the new protocol for chest compressions before definitive cardiac arrest in emergency medical service-witnessed adult out-of-hospital cardiac arrests. Resuscitation 2018; 130:92-98. [DOI: 10.1016/j.resuscitation.2018.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 12/15/2022]
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Sutton RM, Reeder RW, Landis W, Meert KL, Yates AR, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov R, Dean JM, Nadkarni VM, Berg RA. Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes. Resuscitation 2018; 130:159-166. [PMID: 30031055 PMCID: PMC6170369 DOI: 10.1016/j.resuscitation.2018.07.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/08/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
AIM The primary aim of this study was to evaluate the association between chest compression rates and 1) arterial blood pressure and 2) survival outcomes during pediatric in-hospital cardiopulmonary resuscitation (CPR). METHODS Prospective observational study of children ≥37 weeks gestation and <19 years old who received CPR in an intensive care unit (ICU) as part of the Pediatric Intensive Care Unit Quality of CPR Study (PICqCPR) of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Arterial blood pressure and compression rate were determined from manually extracted arterial line waveform data during the first 10 min of CPR. The primary outcome was survival to hospital discharge. Modified Poisson regression models assessed the association between rate categories (80-<100, 100-120 [Guidelines], >120-140, >140) and outcomes. RESULTS Compression rate data were available for 164 patients. More than half (98/164; 60%) were <1 year old. Return of circulation was achieved in 148/164 (90%); survival to hospital discharge in 77/164 (47%). Percentage of events with average rate within Guidelines was 32.9%. Compared to Guidelines, higher rate categories were associated with lower systolic blood pressures (>120-140, p = 0.010; >140, p = 0.077), but not survival. A rate between 80-<100 per minute was associated with a higher rate of survival to hospital discharge (aRR 1.92, CI95 1.13, 3.29, p = 0.017) and survival with favorable neurological outcome (aRR 2.12, CI95 1.09, 4.13, p = 0.027) compared to Guidelines. CONCLUSION Non-compliance with compression rate Guidelines was common in this multicenter cohort. Among ICU patients, slightly lower rates were associated with improved outcomes compared to Guidelines.
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Affiliation(s)
- Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - William Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - John T Berger
- Department of Pediatrics, Children's National Medical Center, Washington D.C., USA
| | - Christopher J Newth
- Department of Anesthesiology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Rick E Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Frank W Moler
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, MI, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington D.C., USA; Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Todd C Carpenter
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Derivation and Internal Validation of a Mortality Prediction Tool for Initial Survivors of Pediatric In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2018; 19:186-195. [PMID: 29239980 PMCID: PMC5834369 DOI: 10.1097/pcc.0000000000001416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To develop a clinical prediction score for predicting mortality in children following return of spontaneous circulation after in-hospital cardiac arrest. DESIGN Observational study using prospectively collected data. SETTING This was an analysis using data from the Get With The Guidelines-Resuscitation registry between January 2000 and December 2015. PATIENTS Pediatric patients (< 18 yr old) who achieved return of spontaneous circulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality. Patients were divided into a derivation (3/4) and validation (1/4) cohort. A prediction score was developed using a multivariable logistic regression model with backward selection. Patient and event characteristics for the derivation cohort (n = 3,893) and validation cohort (n = 1,297) were similar. Seventeen variables associated with the outcome remained in the final reduced model after backward elimination. Predictors of in-hospital mortality included age, illness category, pre-event characteristics, arrest location, day of the week, nonshockable pulseless rhythm, duration of chest compressions, and interventions in place at time of arrest. The C-statistic for the final score was 0.77 (95% CI, 0.75-0.78) in the derivation cohort and 0.77 (95% CI, 0.74-0.79) in the validation cohort. The expected versus observed mortality plot indicated good calibration in both the derivation and validation cohorts. The score showed a stepwise increase in mortality with an observed mortality of less than 15% for scores 0-9 and greater than 80% for scores greater than or equal to 25. The model also performed well for neurologic outcome and in sensitivity analyses for events within the past 5 years and for patients with or without a pulse at the onset of chest compressions. CONCLUSIONS We developed and internally validated a prediction score for initial survivors of pediatric in-hospital cardiac arrest. This prediction score may be useful for prognostication following cardiac arrest, stratifying patients for research, and guiding quality improvement initiatives.
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An Update on Cardiopulmonary Resuscitation in Children. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0216-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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López-Herce J, Rodríguez A, Carrillo A, de Lucas N, Calvo C, Civantos E, Suárez E, Pons S, Manrique I. The latest in paediatric resuscitation recommendations. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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López-Herce J, Rodríguez A, Carrillo A, de Lucas N, Calvo C, Civantos E, Suárez E, Pons S, Manrique I. Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica. An Pediatr (Barc) 2017; 86:229.e1-229.e9. [DOI: 10.1016/j.anpedi.2016.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022] Open
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Abstract
PURPOSE OF REVIEW Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
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Mok YH, Loke APT, Loh TF, Lee JH. Characteristics and Risk Factors for Mortality in Paediatric In-Hospital Cardiac Events in Singapore: Retrospective Single Centre Experience. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2016. [DOI: 10.47102/annals-acadmedsg.v45n12p534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: There is limited data on paediatric resuscitation outcomes in Asia. We aimed to describe outcomes of paediatric in-hospital cardiac arrests (IHCA) and peri-resuscitation factors associated with mortality in our institution. Materials and Methods: Using data from our hospital’s code registry from 2009 to 2014, we analysed all patients younger than 18 years of age with IHCA who required cardiopulmonary resuscitation (CPR). Exposure variables were obtained from clinical demographics, CPR and post-resuscitation data. Outcomes measured were: survival after initial CPR event and survival to hospital discharge. We analysed categorical and continuous variables with Fisher’s exact and Wilcoxon rank-sum tests respectively. Statistical significance was taken as P <0.05. Results: We identified 51 patients in the study period. Median age of patients was 1.9 (interquartile range [IQR]: 0.3, 5.5) years. Twenty-six (51%) patients had bradycardia as the first-recorded rhythm. The most common pre-existing medical condition was respiratory-related (n = 25, 48%). Thirty-eight (75%) achieved sustained return of spontaneous circulation, 24 (47%) survived to paediatric intensive care unit (PICU) discharge and 23 (45%) survived to hospital discharge. Risk factors for hospital mortality included: age, duration of CPR, adrenaline, calcium or bicarbonate administration during CPR, Paediatric Index of Mortality (PIM)-II scores, first recorded post-resuscitation pH and hyperglycaemia within 24 hours of resuscitation. Conclusion: We demonstrated an association between clinical demographics (age, PIM-II scores), CPR variables (duration of CPR and administration of adrenaline, calcium or bicarbonate) and post-resuscitation laboratory results (first recorded pH and hyperglycaemia within 24 hours) with PICU survival. The availability and quality of post-resuscitation care may have implications on survival after paediatric IHCA.
Key words: Cardiopulmonary resuscitation, Child, Infant
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Affiliation(s)
- Yee Hui Mok
- KK Women’s and Children’s Hospital, Singapore
| | | | | | - Jan Hau Lee
- KK Women’s and Children’s Hospital, Singapore
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Outcomes Following Single and Recurrent In-Hospital Cardiac Arrests in Children With Heart Disease: A Report From American Heart Association's Get With the Guidelines Registry-Resuscitation. Pediatr Crit Care Med 2016; 17:531-9. [PMID: 26914627 DOI: 10.1097/pcc.0000000000000678] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Little is known regarding patient characteristics and outcomes associated with cardiac arrest in hospitalized children with underlying heart disease. We described clinical characteristics and in-hospital outcomes in cardiac patients with both single and recurrent cardiac arrests. DESIGN Retrospective analysis evaluating characteristics and outcomes in single versus recurrent arrest groups in unadjusted and adjusted analyses. SETTING American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2010). PATIENTS Children younger than 18 years, identified with medical or surgical cardiac disease and one or more in-hospital cardiac arrest. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One thousand eight hundred and eighty-nine patients with 2,387 cardiac arrests from 157 centers met inclusion criteria: 1,546 (82%) with a single arrest and 343 (18%) with a recurrent arrest. More than two thirds of recurrent cardiac arrests occurred in ICUs, and those with recurrent arrest had a higher prevalence of baseline comorbidities (e.g., more likely to be mechanically ventilated and receiving vasoactive infusions). Overall survival to hospital discharge was 51%, and was lower in the recurrent versus single arrest group (41% vs 53%; p < 0.001). In analysis adjusted for baseline comorbidities, there was no longer a statistically significant association between recurrent arrest and survival (odds ratio, 0.74; 95% CI, 0.33-1.63; p = 0.45). In stratified analysis, the relationship between recurrent arrest and lower survival was more prominent in the surgical-cardiac (odds ratio, 0.39; 95% CI, 0.14-1.11; p = 0.09) versus medical-cardiac (odds ratio, 0.96; 95% CI, 0.28-3.30; p = 0.95) group. CONCLUSIONS In this large multicenter study, half of pediatric cardiac patients who suffered a cardiac arrest survived to hospital discharge. Lower survival in the group with recurrent arrest may be explained in part by the higher prevalence of baseline comorbidities in these patients, and surgical cardiac patients appeared to be at greatest risk. Further study is necessary to develop strategies to reduce subsequent mortality in these high-risk patients.
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Basismaßnahmen der kardiopulmonalen Reanimation bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lasa JJ, Rogers RS, Localio R, Shults J, Raymond T, Gaies M, Thiagarajan R, Laussen PC, Kilbaugh T, Berg RA, Nadkarni V, Topjian A. Extracorporeal Cardiopulmonary Resuscitation (E-CPR) During Pediatric In-Hospital Cardiopulmonary Arrest Is Associated With Improved Survival to Discharge: A Report from the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry. Circulation 2016; 133:165-76. [PMID: 26635402 PMCID: PMC4814337 DOI: 10.1161/circulationaha.115.016082] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although extracorporeal cardiopulmonary resuscitation (E-CPR) can result in survival after failed conventional CPR (C-CPR), no large, systematic comparison of pediatric E-CPR and continued C-CPR has been reported. METHODS AND RESULTS Consecutive patients <18 years old with CPR events ≥10 minutes in duration reported to the Get With the Guidelines-Resuscitation registry between January 2000 and December 2011 were identified. Hospitals were grouped by teaching status and location. Primary outcome was survival to discharge. Regression modeling was performed, conditioning on hospital groups. A secondary analysis was performed with the use of propensity score matching. Of 3756 evaluable patients, 591 (16%) received E-CPR and 3165 (84%) received C-CPR only. Survival to hospital discharge and survival with favorable neurological outcome (Pediatric Cerebral Performance Category score of 1-3 or unchanged from admission) were greater for E-CPR (40% [237 of 591] and 27% [133 of 496]) versus C-CPR patients (27% [862 of 3165] and 18% [512 of 2840]). Odds ratios (ORs) for survival to hospital discharge and survival with favorable neurological outcome were greater for E-CPR versus C-CPR. After adjustment for covariates, patients receiving E-CPR had higher odds of survival to discharge (OR, 2.80; 95% confidence interval, 2.13-3.69; P<0.001) and survival with favorable neurological outcome (OR, 2.64; 95% confidence interval, 1.91-3.64; P<0.001) than patients who received C-CPR. This association persisted when analyzed by propensity score-matched cohorts (OR, 1.70; 95% confidence interval, 1.33-2.18; P<0.001; and OR, 1.78; 95% confidence interval, 1.31-2.41; P<0.001, respectively]. CONCLUSION For children with in-hospital CPR of ≥10 minutes duration, E-CPR was associated with improved survival to hospital discharge and survival with favorable neurological outcome compared with C-CPR.
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Affiliation(s)
- Javier J Lasa
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.).
| | - Rachel S Rogers
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Russell Localio
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Justine Shults
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Tia Raymond
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Michael Gaies
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Ravi Thiagarajan
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Peter C Laussen
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Todd Kilbaugh
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Robert A Berg
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Vinay Nadkarni
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
| | - Alexis Topjian
- From Texas Children's Hospital, Houston (J.J.L.); Children's Hospital of Philadelphia, PA (R.S.R., R.L., J.S., T.K., R.A.B., V.N., A.T.); Medical City Children's Hospital, Dallas, TX (T.R.); University of Michigan C.S. Mott Children's Hospital, Ann Arbor (M.G.); Boston Children's Hospital, MA (R.T.); and Toronto Sick Kids Hospital, Canada (P.C.L.)
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Cheng A, Hunt EA, Grant D, Lin Y, Grant V, Duff JP, White ML, Peterson DT, Zhong J, Gottesman R, Sudikoff S, Doan Q, Nadkarni VM, Brown L, Overly F, Bank I, Bhanji F, Kessler D, Tofil N, Davidson J, Adler M, Bragg A, Marohn K, Robertson N, Duval-Arnould J, Wong H, Donoghue A, Chatfield J, Chime N. Variability in quality of chest compressions provided during simulated cardiac arrest across nine pediatric institutions. Resuscitation 2015; 97:13-9. [PMID: 26417701 DOI: 10.1016/j.resuscitation.2015.08.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/14/2015] [Accepted: 08/17/2015] [Indexed: 10/23/2022]
Abstract
AIM The variability in quality of CPR provided during cardiac arrest across pediatric institutions is unknown. We aimed to describe the degree of variability in the quality of CPR across 9 pediatric institutions, and determine if variability across sites would be affected by Just-in-Time CPR training and/or visual feedback during simulated cardiac arrest. METHODS We conducted secondary analyses of data collected from a prospective, multi-center trial. Participants were equally randomized to either: (1) No intervention; (2) Real-time CPR visual feedback during cardiac arrest or (3) Just-in-Time CPR training. We report the variability in median chest compression depth and rate across institutions, and the variability in the proportion of 30-s epochs of CPR meeting 2010 American Heart Association guidelines for depth and rate. RESULTS We analyzed data from 528 epochs in the no intervention group, 552 epochs in the visual feedback group, and 525 epochs in the JIT training group. In the no intervention group, compression depth (median range 22.2-39.2mm) and rate (median range 116.0-147.6 min(-1)) demonstrated significant variability between study sites (p<0.001). The proportion of compressions with adequate depth (0-11.5%) and rate (0-60.5%) also varied significantly across sites (p<0.001). The variability in compression depth and rate persisted despite use of real-time visual feedback or JIT training (p<0.001). CONCLUSION The quality of CPR across multiple pediatric institutions is variable. Variability in CPR quality across institutions persists even with the implementation of a Just-in-Time training session and visual feedback for CPR quality during simulated cardiac arrest.
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Affiliation(s)
- Adam Cheng
- University of Calgary, KidSim-ASPIRE Research Program, Division of Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, 2888 Shaganappi Trail NW, Calgary, AB, Canada T3B 6A8.
| | - Elizabeth A Hunt
- Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Division of Pediatric Anesthesiology and Critical Care Medicine, 1800 Orleans Street/Room 6321, Baltimore, MD 21287, USA.
| | - David Grant
- Bristol Royal Hospital for Children, University Hospitals Bristol, Paul O'Gorman Building, Upper Maudin St, Bristol BS2 8BJ, UK.
| | - Yiqun Lin
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, Canada T3B 6A8.
| | - Vincent Grant
- KidSIM-ASPIRE Simulation Research Program, Alberta Children's Hospital, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB, Canada T3B 6A8.
| | - Jonathan P Duff
- Stollery Children's Hospital, University of Alberta, 8215 112 St NW, Edmonton, AB, Canada T6G 2L9.
| | - Marjorie Lee White
- Pediatric Simulation Center, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave, S., Birmingham, AL 35233, USA.
| | - Dawn Taylor Peterson
- Pediatric Simulation Center, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave, S., Birmingham, AL 35233, USA.
| | - John Zhong
- Children's Medical Center of Dallas, UT Southwestern Medical Center, 1935 Medical District Dr, Dallas, TX 75235, USA.
| | - Ronald Gottesman
- Montreal Children's Hospital, McGill University, 2300 Tupper St, Montreal, QC, Canada H3H 1P3.
| | - Stephanie Sudikoff
- Yale-New Haven Health, Yale Medical School, 730 Howard Ave, New Haven, CT 06519, USA.
| | - Quynh Doan
- British Columbia Children's Hospital, University of British Columbia, 4480 Oak Street, Vancouver, BC, Canada V6H 3V4.
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Phillips RS, Scott B, Carter SJ, Taylor M, Peirce E, Davies P, Maconochie IK. Systematic review and meta-analysis of outcomes after cardiopulmonary arrest in childhood. PLoS One 2015; 10:e0130327. [PMID: 26107958 PMCID: PMC4479568 DOI: 10.1371/journal.pone.0130327] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/19/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest in children is an uncommon event, and often fatal. Resuscitation is often attempted, but at what point, and under what circumstances do continued attempts to re-establish circulation become futile? The uncertainty around these questions can lead to unintended distress to the family and to the resuscitation team. OBJECTIVES To define the likely outcomes of cardiopulmonary resuscitation in children, within different patient groups, related to clinical features. DATA SOURCES MEDLINE, MEDLINE in-Process & Other non-Indexed Citations, EMBASE, Cochrane database of systematic reviews and Cochrane central register of trials, Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment database, along with reference lists of relevant systematic reviews and included articles. STUDY ELIGIBILITY CRITERIA Prospective cohort studies which derive or validate a clinical prediction model of outcome following cardiopulmonary arrest. PARTICIPANTS AND INTERVENTIONS Children or young people (aged 0 - 18 years) who had cardiopulmonary arrest and received an attempt at resuscitation, excluding resuscitation at birth. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias assessment developed the Hayden system for non-randomised studies and QUADAS2 for decision rules. Synthesis undertaken by narrative, and random effects meta-analysis with the DerSimonian-Laird estimator. RESULTS More than 18,000 episodes in 16 data sets were reported. Meta-analysis was possible for survival and one neurological outcome; others were reported too inconsistently. In-hospital patients (average survival 37.2% (95% CI 23.7 to 53.0%)) have a better chance of survival following cardiopulmonary arrest than out-of-hospital arrests (5.8% (95% CI 3.9% to 8.6%)). Better neurological outcome was also seen, but data were too scarce for meta-analysis (17% to 71% 'good' outcomes, compared with 2.8% to 3.2%). LIMITATION Lack of consistent outcome reporting and short-term neurological outcome measures limited the strength of conclusions that can be drawn from this review. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS There is a need to collaboratively, prospectively, collect potentially predictive data on these rare events to understand more clearly the predictors of survival and long-term neurological outcome. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2013:CRD42013005102.
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Affiliation(s)
- Robert S. Phillips
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
- Leeds Children’s Hospital, Leeds General Infirmary, Leeds, United Kingdom
- * E-mail:
| | | | | | - Matthew Taylor
- Leeds Children’s Hospital, Leeds General Infirmary, Leeds, United Kingdom
| | - Eleanor Peirce
- Sheffield Children’s Hospital, Sheffield, United Kingdom
| | - Patrick Davies
- Nottingham Children's Hospital, Nottingham Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ian K. Maconochie
- St Mary’s Hospital, Imperial College NHS Healthcare Trust, London, United Kingdom
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Cardiopulmonary resuscitation for in-hospital events in the emergency department: A comparison of adult and pediatric outcomes and care processes. Resuscitation 2015; 92:94-100. [PMID: 25939323 DOI: 10.1016/j.resuscitation.2015.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 03/25/2015] [Accepted: 04/23/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To compare outcomes from in-hospital cardiopulmonary resuscitation (CPR) in the emergency department (ED) for pediatric and adult patients and to identify factors associated with differences in outcomes between children and adults. METHODS Retrospective analysis of the Get With The Guidelines--Resuscitation database from January 1, 2000 to September 30, 2010. All patients with CPR initiated in the ED requiring chest compressions for ≥ 2 min were eligible; trauma patients were excluded. Patients were divided into children (<18 yo) and adults (≥ 18 yo). Patient, event, treatment, and hospital factors were analyzed for association with outcomes. Univariate analysis was performed comparing children and adults. Multivariate analysis was used to determine factors associated with outcomes. RESULTS 16,834 events occurred in 608 centers (16,245 adult, 537 pediatric). Adults had more frequent return of spontaneous circulation (53% vs 47%, p = 0.02), 24h survival (35% vs 30%, p = 0.02), and survival to discharge (23% vs 20%, p = NS) than children. Children were less frequently monitored (62% vs 82%) or witnessed (79% vs 88%), had longer duration (24 m vs 17 m), more epinephrine doses (3 vs 2), and more frequent intubation attempts (64% vs 55%) than adults. There were no differences in time to compressions, vasopressor administration, or defibrillation between children and adults. On multivariate analysis, age had no association with outcomes. CONCLUSIONS Survival following CPR in the ED is similar for adults and children. While univariate differences exist between children and adults, neither age nor specific processes of care are independently associated with outcomes.
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Abstract
OBJECTIVE In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events. DESIGN, SETTING, AND PATIENTS Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU. INTERVENTIONS Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers. MEASUREMENTS AND MAIN RESULTS Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01). CONCLUSION Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.
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Variability of characteristics and outcomes following cardiopulmonary resuscitation events in diverse ICU settings in a single, tertiary care children's hospital*. Pediatr Crit Care Med 2014; 15:e128-41. [PMID: 24413318 DOI: 10.1097/pcc.0000000000000067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The primary objective of this study was to compare and contrast the characteristics and survival outcomes of cardiopulmonary resuscitation for "monitored" events in pediatric patients treated with chest compressions more than or equal to 1 minute in varied ICU settings. DESIGN Retrospective observational study. SETTING Three different specialized ICUs in a single, tertiary care, academic children's hospital. PATIENTS We collected demographic information, preexisting conditions, preevent characteristics, event characteristics, and outcome data. The primary outcome measure was survival to hospital discharge. Secondary outcome measures included return of spontaneous circulation, 24-hour survival, and survival with good neurologic outcome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four hundred eleven patients treated with chest compressions for more than or equal to 1 minute were included in the analysis: 170 patients were located in the cardiovascular ICU, 157 patients in the neonatal ICU, and 84 patients in the PICU. Arrest durations were longer in the cardiovascular ICU than other ICUs. Use of extracorporeal cardiopulmonary resuscitation was more prevalent in the cardiovascular ICU (cardiovascular ICU, 17%; neonatal ICU, 3%; PICU, 4%). Return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and good neurologic outcome were highest among neonatal ICU patients (survival to discharge, 53%) followed by cardiovascular ICU patients (survival to discharge, 46%) and PICU patients (survival to discharge, 36%). In a multivariable model controlling for patient and event characteristics, using cardiovascular ICU as reference, adjusted odds of survival in PICU were 0.33 (95% CI, 0.14-0.76; p = 0.009) and odds of survival in neonatal ICU were 0.80 (95% CI, 0.31-2.11; p = 0.65). CONCLUSIONS Comparative analysis of pediatric patients undergoing cardiopulmonary resuscitation in three different ICU settings demonstrated a significant variation in baseline, preevent, and event characteristics. Although outcomes vary significantly among the three different ICUs, it was difficult to ascertain if this difference was due to variation in the disease process or variation in the location of the patient.
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Abstract
OBJECTIVES The aim of this study was to evaluate the relative frequency of pediatric in-hospital cardiopulmonary resuscitation events occurring in ICUs compared to general wards. We hypothesized that the proportion of pediatric cardiopulmonary resuscitation provided in ICUs versus general wards has increased over the past decade, and this shift is associated with improved resuscitation outcomes. DESIGN Prospective and observational study. SETTING Total of 315 hospitals in the American Heart Association's Get With The Guidelines-Resuscitation database. PATIENTS Total of 5,870 pediatric cardiopulmonary resuscitation events between January 1, 2000 and September 14, 2010. Cardiopulmonary resuscitation events were defined as external chest compressions longer than 1 minute. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was proportion of total ICU versus general ward cardiopulmonary resuscitation events over time evaluated by chi-square test for trend. Secondary outcome included return of spontaneous circulation following the cardiopulmonary resuscitation event. Among 5,870 pediatric cardiopulmonary resuscitation events, 5,477 (93.3%) occurred in ICUs compared to 393 (6.7%) in inpatient wards. Over time, significantly more of these cardiopulmonary resuscitation events occurred in the ICU compared to the wards (test for trend: p<0.01), with a prominent shift noted between 2003 and 2004 (2000-2003: 87-91% vs 2004-2010: 94-96%). In a multivariable model controlling for within center variability and other potential confounders, return of spontaneous circulation increased in 2004-2010 compared with 2000-2003 (relative risk, 1.08; 95% CI, 1.03-1.13). CONCLUSIONS In-hospital pediatric cardiopulmonary resuscitation is much more commonly provided in ICUs than in wards, and the proportion has increased significantly over the past decade, with concomitant increases in return of spontaneous circulation.
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Lowry AW, Morales DLS, Graves DE, Knudson JD, Shamszad P, Mott AR, Cabrera AG, Rossano JW. Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United States: analysis of the kids' inpatient database. Pediatr Cardiol 2013; 34:1422-30. [PMID: 23503928 DOI: 10.1007/s00246-013-0666-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 02/09/2013] [Indexed: 10/27/2022]
Abstract
To characterize the overall use, cost, and outcomes of extracorporeal membrane oxygenation (ECMO) as an adjunct to cardiopulmonary resuscitation (CPR) among hospitalized infants and children in the United States, retrospective analysis of the 2000, 2003, and 2006 Kids' Inpatient Database (KID) was performed. All CPR episodes were identified; E-CPR was defined as ECMO used on the same day as CPR. Channeling bias was decreased by developing propensity scores representing the likelihood of requiring E-CPR. Univariable, multivariable, and propensity-matched analyses were performed to characterize the influence of E-CPR on survival. There were 8.6 million pediatric hospitalizations and 9,000 CPR events identified in the database. ECMO was used in 82 (0.9 %) of the CPR events. Median hospital charges for E-CPR survivors were $310,824 [interquartile range (IQR) 263,344-477,239] compared with $147,817 (IQR 62,943-317,553) for propensity-matched conventional CPR (C-CPR) survivors. Median LOS for E-CPR survivors (31 days) was considerably greater than that of propensity-matched C-CPR survivors (18 days). Unadjusted E-CPR mortality was higher relative to C-CPR (65.9 vs. 50.9 %; OR 1.9, 95 % confidence interval 1.2-2.9). Neither multivariable analysis nor propensity-matched analysis identified a significant difference in survival between groups. E-CPR is infrequently used for pediatric in-hospital cardiac arrest. Median LOS and charges are considerably greater for E-CPR survivors with C-CPR survivors. In this retrospective administrative database analysis, E-CPR did not significantly influence survival. Further study is needed to improve outcomes and to identify patients most likely to benefit from this resource-intensive therapy.
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Affiliation(s)
- Adam W Lowry
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, 750 Welch Rd, Suite 325, Palo Alto, CA 94306, USA.
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Topjian AA, Berg RA, Nadkarni VM. Advances in recognition, resuscitation, and stabilization of the critically ill child. Pediatr Clin North Am 2013; 60:605-20. [PMID: 23639658 DOI: 10.1016/j.pcl.2013.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in early recognition, effective response, and high-quality resuscitation before, during, and after cardiac arrest have resulted in improved survival for infants and children over the past 10 years. This review addresses several key factors that can make a difference in survival outcomes, including the etiology of pediatric cardiac arrests in and out of hospital, mechanisms and techniques of circulation of blood flow during cardiopulmonary resuscitation (CPR), quality of CPR, meticulous postresuscitative care, and effective training. Monitoring and quality improvement of each element in the system of resuscitation care are increasingly recognized as key factors in saving lives.
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Affiliation(s)
- Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA 19063, USA
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Bennett KS, Clark AE, Meert KL, Topjian AA, Schleien CL, Shaffner DH, Dean JM, Moler FW. Early oxygenation and ventilation measurements after pediatric cardiac arrest: lack of association with outcome. Crit Care Med 2013; 41:1534-42. [PMID: 23552509 PMCID: PMC3683244 DOI: 10.1097/ccm.0b013e318287f54c] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To explore oxygenation and ventilation status early after cardiac arrest in infants and children. We hypothesize that hyperoxia is common and associated with worse outcome after pediatric cardiac arrest. DESIGN Retrospective cohort study. SETTING Fifteen hospitals within the Pediatric Emergency Care Applied Research Network. PATIENTS Children who suffered a cardiac arrest event and survived for at least 6 hours after return of circulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis of 195 events revealed that abnormalities in oxygenation and ventilation are common during the initial 6 hours after pediatric cardiac arrest. Hyperoxia was frequent, affecting 54% of patients. Normoxia was documented in 34% and hypoxia in 22% of patients. These percentages account for a 10% overlap of patients who had both hyperoxia and hypoxia. Ventilation status was more evenly distributed with hyperventilation observed in 38%, normoventilation in 29%, and hypoventilation in 46%, with a 13% overlap of patients who had both hyperventilation and hypoventilation. Derangements in both oxygenation and ventilation were common early after cardiac arrest such that both normoxia and normocarbia were documented in only 25 patients (13%). Neither oxygenation nor ventilation status was associated with outcome. After controlling for potential confounders, arrest location and rhythm were significantly associated with worse outcome; however, hyperoxia was not (odds ratio for good outcome, 1.02 [0.46, 2.84]; p = 0.96). CONCLUSIONS Despite recent resuscitation guidelines that advocate maintenance of normoxia and normoventilation after pediatric cardiac arrest, this is uncommonly achieved in practice. Although we did not demonstrate an association between hyperoxia and worse outcome, the small proportion of patients kept within normal ranges limited our power. Preclinical data suggesting potential harm with hyperoxia remain compelling, and further investigation, including prospective, large studies involving robust recording of physiological derangements, is necessary to further advance our understanding of this important topic.
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Cardiopulmonary resuscitation in hospitalized children with cardiovascular disease: estimated prevalence and outcomes from the kids' inpatient database. Pediatr Crit Care Med 2013; 14:248-55. [PMID: 23462352 DOI: 10.1097/pcc.0b013e3182713329] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hospitalized children with cardiovascular disease may be at increased risk of cardiac arrest; however, little data exist regarding prevalence, risk factors, or outcomes of cardiopulmonary resuscitation in these patients. We sought to characterize national estimates of cardiopulmonary resuscitation and death after cardiopulmonary resuscitation for hospitalized children with cardiovascular disease. SETTING A total of 3,739 hospitals in 38 states participating in Kids' Inpatient Database. DESIGN Retrospective analysis of the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database was performed. Sample weighting was employed to produce national estimates. MEASUREMENTS AND MAIN RESULTS Cardiovascular disease was identified in 2.2% of the estimated 22,175,468 (95% confidence interval 21,391,343-22,959,592) hospitalizations. Cardiopulmonary resuscitation occurred in 0.74% (3,698; 95% confidence interval 3,205-4,191) of hospitalizations of children with cardiovascular disease, compared with 0.05% (11,726; 95% confidence interval 10,647-12,805) without cardiovascular disease (odds ratio 13.8, 95% confidence interval 12.8-15.0). The highest frequency of cardiopulmonary resuscitation occurred with myocarditis (3.0% of admissions), heart failure (2.0%), and coronary pathology (2.0%). Compared with other forms of cardiovascular disease identified in this study, single-ventricle patients were the only subgroup who exhibited a higher mortality after cardiopulmonary resuscitation (mortality 65% vs. 55%; odds ratio 1.7 [95% confidence interval 1.2-2.6]), while those who had undergone cardiac surgery exhibited a lower mortality rate (mortality 48% vs. 57%; odds ratio 0.6 [95% confidence interval 0.5-0.8]). CONCLUSIONS Cardiopulmonary resuscitation occurs in approximately 7 per 1,000 hospitalizations of children with cardiovascular disease, a rate greater than ten-fold that observed in hospitalizations of children without cardiovascular disease. Single-ventricle patients demonstrated increased mortality after cardiopulmonary resuscitation, while recent cardiac surgery was associated with a reduced odds of death after cardiopulmonary resuscitation. Further studies are needed to confirm these findings and develop techniques to prevent cardiac arrest in this high-risk population.
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Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, Carroll CL, Berens RJ, Praestgaard A, Weissfeld L, Spinella PC. Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests. Circulation 2013; 127:442-51. [DOI: 10.1161/circulationaha.112.125625] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned, although the effect of CPR duration on outcomes has not recently been described. Our objective was to determine the relationship between CPR duration and outcomes after pediatric in-hospital cardiac arrests.
Methods and Results—
We examined the effect of CPR duration for pediatric in-hospital cardiac arrests from the Get With The Guidelines–Resuscitation prospective, multicenter registry of in-hospital cardiac arrests. We included 3419 children from 328 US and Canadian Get With The Guidelines–Resuscitation sites with an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma. Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes. Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute. Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes. Among survivors, favorable neurological outcome occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes. Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8–3.4) and 2.7 (95% confidence interval, 2.0–3.9), respectively.
Conclusions—
CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
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Affiliation(s)
- Renée I. Matos
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - R. Scott Watson
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Vinay M. Nadkarni
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Hsin-Hui Huang
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Robert A. Berg
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Peter A. Meaney
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Christopher L. Carroll
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Richard J. Berens
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Amy Praestgaard
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Lisa Weissfeld
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
| | - Philip C. Spinella
- From the CRISMA Center, Pittsburgh, PA (R.I.M., R.S.W, L.W.); Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (R.I.M., R.S.W.); Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX (R.I.M.); The Children’s Hospital of Philadelphia, Philadelphia, PA (V.M.N., R.A.B., P.A.M.); Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (H.-H.H., L.W.); Connecticut Children’s Medical
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