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Blinder JJ, Alten J, Bailly D, Buckley J, Clarke S, Diddle JW, Garcia X, Gist KM, Koch J, Kwiatkowski DM, Rahman AKMF, Reichle G, Valentine K, Hock KM, Borasino S. Diuretic response after neonatal cardiac surgery: a report from the NEPHRON collaborative. Pediatr Nephrol 2024:10.1007/s00467-024-06380-y. [PMID: 38713228 DOI: 10.1007/s00467-024-06380-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Multicenter early diuretic response (DR) analysis of single furosemide dosing following neonatal cardiac surgery is lacking to inform whether early DR predicts adverse clinical outcomes. METHODS We performed a retrospective cohort study utilizing data from the NEPHRON registry. Random forest machine learning generated receiver operating characteristic-area under the curve (ROC-AUC) and odds ratios for mechanical ventilation (MV) and respiratory support (RS). Prolonged MV and RS were defined using ≥ 90th percentile of observed/expected ratios. Secondary outcomes were prolonged CICU and hospital length of stay (LOS) and kidney failure (stage III acute kidney injury (AKI), peritoneal dialysis, and/or continuous kidney replacement therapy on postoperative day three) assessed using covariate-adjusted ROC-AUC curves. RESULTS A total of 782 children were included. Cumulative urine output (UOP) metrics were lower in prolonged MV and RS patients, but DR poorly predicted prolonged MV (highest AUC 0.611, OR 0.98, sensitivity 0.67, specificity 0.53, p = 0.006, 95% OR CI 0.96-0.99 for cumulative 6-h UOP) and RS (highest AUC 0.674, OR 0.94, sensitivity 0.75, specificity 0.54, p < 0.001, 95% CI 0.91-0.97 UOP between 3 and 6 h). Secondary outcome results were similar. DR had fair discrimination for kidney failure (AUC 0.703, OR 0.94, sensitivity 0.63, specificity 0.71, 95% OR CI 0.91-0.98, p < 0.001, cumulative 6-h UOP). CONCLUSIONS Early DR poorly discriminated patients with prolonged MV, RS, and LOS in this cohort, though it may identify severe postoperative AKI phenotype. Future work is warranted to determine if early DR or late postoperative DR later, in combination with other AKI metrics, may identify a higher-risk phenotype.
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Affiliation(s)
- Joshua J Blinder
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, 94304, USA.
| | - Jeffrey Alten
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - Jason Buckley
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Shanelle Clarke
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Xiomara Garcia
- Division of Pediatric Cardiology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AK, USA
| | - Katja M Gist
- Division of Pediatric Cardiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Joshua Koch
- Division of Critical Care, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David M Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA, 94304, USA
| | - A K M Fazlur Rahman
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Garrett Reichle
- Division of Pediatric Cardiology, Department of Pediatrics, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Children's Hospital, Indiana University, Indianapolis, IN, USA
| | - Kristal M Hock
- Section of Pediatric Cardiac Critical Care, Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, Birmingham, AL, USA
| | - Santiago Borasino
- Section of Pediatric Cardiac Critical Care, Division of Cardiology, Department of Pediatrics, University of Alabama, Birmingham, Birmingham, AL, USA
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Yates AR, Naim MY, Reeder RW, Ahmed T, Banks RK, Bell MJ, Berg RA, 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, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yeh J, Zuppa AF, Sutton RM, Meert KL. Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021). Pediatr Crit Care Med 2024; 25:312-322. [PMID: 38088765 PMCID: PMC10994777 DOI: 10.1097/pcc.0000000000003423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients. DESIGN Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497). SETTING Eighteen ICUs participated in ICU-RESUS. PATIENTS There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation. CONCLUSIONS We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.
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Affiliation(s)
- Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Justin Yeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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Frazier AH, Topjian AA, Reeder RW, Morgan RW, Fink EL, Franzon D, Graham K, Harding ML, Mourani PM, Nadkarni VM, Wolfe HA, Ahmed T, Bell MJ, Burns C, Carcillo JA, Carpenter TC, Diddle JW, Federman M, Friess SH, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Meert KL, Naim MY, Notterman D, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Yates AR, Sutton RM, Berg RA. Association of Pediatric Post-Cardiac Arrest Ventilation and Oxygenation with Survival Outcomes. Ann Am Thorac Soc 2024. [PMID: 38507645 DOI: 10.1513/annalsats.202311-948oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
RATIONALE Adult and pediatric studies provide conflicting data whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia and/or hypocapnia are associated with worse outcomes. OBJECTIVES Determine if post-arrest hypoxemia or post-arrest hyperoxemia are associated with lower rates of survival to hospital discharge compared to post-arrest normoxemia, and if post-arrest hypocapnia or hypercapnia are associated with lower rates of survival compared to post-arrest normocapnia. METHODS Embedded prospective observational study during a multi-center interventional cardiopulmonary resuscitation trial from 2016-2021. Patients ≤18 years and ≥37 weeks corrected gestational age who received chest compressions for cardiac arrest in one of 18 ICUs were included. Exposures during the first 24 hours post-arrest were hypoxemia, hyperoxemia, or normoxemia defined as lowest PaO2 <60mmHg, highest PaO2 ≥200mmHg, or every PaO2 60-199mmHg, respectively, and hypocapnia, hypercapnia, or normocapnia defined as lowest PaCO2 <30mmHg, highest PaCO2 ≥50mmHg, or every PaCO2 30-49mmHg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. MEASUREMENTS AND MAIN RESULTS The hypoxemia group was less likely to survive to hospital discharge compared with the normoxemia group (aRR 0.71, 0.58-0.87), whereas the hyperoxemia group survival did not differ from the normoxemia group (aRR 1.0, 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge compared with the normocapnia group (aRR 0.74, 0.64-0.84), whereas the hypocapnia group survival did not differ from the normocapnia group (aRR 0.91, 0.74-1.12). CONCLUSIONS Post-arrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Aisha H Frazier
- Nemours Children's Hospital Delaware, 25401, Cardiac Center, Wilmington, Delaware, United States
- Thomas Jefferson University Sidney Kimmel Medical College, 12313, Pediatrics, Philadelphia, Pennsylvania, United States
| | - Alexis A Topjian
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Ron W Reeder
- University of Utah, Department of Pediatrics, Salt Lake City, Utah, United States
| | - Ryan W Morgan
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Ericka L Fink
- Children's Hospital of Pittsburgh of UPMC, 6619, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States
| | - Deborah Franzon
- UCSF Benioff Children's Hospital, 21642, Department of Pediatrics, San Francisco, California, United States
| | - Kathryn Graham
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States
| | - Monica L Harding
- University of Utah, Department of Pediatrics, Salt Lake City, Utah, United States
| | - Peter M Mourani
- University of Arkansas for Medical Sciences, 12215, Pediatrics, Critical Care Medicine, Little Rock, Arkansas, United States
- Arkansas Childrens Research Institute, 366944, Little Rock, Arkansas, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Heather A Wolfe
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Tageldin Ahmed
- Children's Hospital of Michigan, 2969, Department of Pediatrics , Detroit, Michigan, United States
| | - Michael J Bell
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Candice Burns
- Washington University School of Medicine in Saint Louis, 12275, Department of Pediatrics, St Louis, Missouri, United States
| | - Joseph A Carcillo
- Children's Hospital of Pittsburgh of UPMC Department of Pediatric Critical Care Medicine, 549368, Pittsburgh, Pennsylvania, United States
| | - Todd C Carpenter
- University of Colorado School of Medicine, 12225, Aurora, Colorado, United States
- Children's Hospital Colorado, 2932, Department of Pediatrics, Aurora, Colorado, United States
| | - J Wesley Diddle
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Myke Federman
- University of California Los Angeles, 8783, Los Angeles, California, United States
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
| | - Stuart H Friess
- Washington University School of Medicine in Saint Louis, 12275, Department of Pediatrics, St Louis, Missouri, United States
| | - Mark Hall
- Nationwide Children's Hospital, 2650, Department of Pediatrics, Columbus, Ohio, United States
- The Ohio State University, 2647, Columbus, Ohio, United States
| | - David A Hehir
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Christopher M Horvat
- Children's Hospital of Pittsburgh of UPMC, 6619, Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States
- University of Pittsburgh, 6614, Pittsburgh, Pennsylvania, United States
| | - Leanna L Huard
- University of California Los Angeles, 8783, Los Angeles, California, United States
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
| | - Tensing Maa
- Nationwide Children's Hospital, 2650, Department of Pediatrics , Columbus, Ohio, United States
- The Ohio State University, 2647, Columbus, Ohio, United States
| | - Kathleen L Meert
- Children's Hospital of Michigan, 2969, Department of Pediatrics, Detroit, Michigan, United States
- Central Michigan University, 5649, Mount Pleasant, Michigan, United States
| | - Maryam Y Naim
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Daniel Notterman
- Princeton University, 6740, Department of Molecular Biology, Princeton, New Jersey, United States
| | - Murray M Pollack
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Carleen Schneiter
- University of Colorado School of Medicine, 12225, Aurora, Colorado, United States
- Children's Hospital Colorado, 2932, Department of Pediatrics , Aurora, Colorado, United States
| | - Matthew P Sharron
- Children's National Medical Center, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Neeraj Srivastava
- UCLA Mattel Children's Hospital, 21785, Department of Pediatrics, Los Angeles, California, United States
- University of California Los Angeles, 8783, Los Angeles, California, United States
| | - Shirley Viteri
- Nemours Children's Hospital Delaware, 25401, Department of Pediatrics, Wilmington, Delaware, United States
- Thomas Jefferson University Sidney Kimmel Medical College, 12313, Philadelphia, Pennsylvania, United States
| | - David Wessel
- Children's National Hospital, 8404, Department of Pediatrics, Washington, District of Columbia, United States
- The George Washington University School of Medicine and Health Sciences, 43989, Washington, District of Columbia, United States
| | - Andrew R Yates
- Nationwide Children's Hospital, 2650, Pediatrics, Columbus, Ohio, United States
- The Ohio State University, 2647, Pediatrics, Columbus, Ohio, United States
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, 6567, Department of Anesthesiology and Critical Care Medicine, Philadelphia, Pennsylvania, United States
- University of Pennsylvania, 6572, Philadelphia, Pennsylvania, United States;
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4
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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5
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Federman M, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kirkpatrick T, Maa T, Maitoza LA, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Naim MY. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatr Crit Care Med 2024; 25:4-14. [PMID: 37678381 PMCID: PMC10843749 DOI: 10.1097/pcc.0000000000003368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease. DESIGN Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021). SETTING Eighteen PICUs. PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups. CONCLUSIONS In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.
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Affiliation(s)
- Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - 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
| | - 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 A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 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 Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, 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 Hospital, Delaware, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, St. Louis, MO, 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
| | - 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
| | - Theresa Kirkpatrick
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Laura A Maitoza
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, 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
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 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, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, 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 Children’s Hospital, Delaware 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
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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6
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Gardner MM, Hehir DA, Reeder RW, Ahmed T, Bell MJ, Berg RA, 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, Harding ML, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Morgan RW, 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, Sutton RM, Topjian AA. Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study. Crit Care 2023; 27:388. [PMID: 37805481 PMCID: PMC10559632 DOI: 10.1186/s13054-023-04662-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge. METHODS We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. RESULTS Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001). CONCLUSIONS Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.
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Affiliation(s)
- Monique M Gardner
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, 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
| | - 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 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
| | - 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 and Thomas Jefferson University, Wilmington, DE, 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
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, 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
| | - 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
| | - 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
| | - 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, 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 Children's Health 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, 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
| | - 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
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7
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Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest. Resuscitation 2023; 191:109939. [PMID: 37625580 PMCID: PMC10528057 DOI: 10.1016/j.resuscitation.2023.109939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
AIM To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest. METHODS This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status. RESULTS Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites. CONCLUSIONS Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Robert Bishop
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Heather A Wolfe
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Centre Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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8
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Morgan RW, Reeder RW, Ahmed T, Bell MJ, Berger JT, 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, Himebauch AS, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial. Resuscitation 2023; 190:109897. [PMID: 37406760 PMCID: PMC10530491 DOI: 10.1016/j.resuscitation.2023.109897] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes. METHODS This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR. RESULTS Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups. CONCLUSIONS In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, 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
| | - John T Berger
- 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
| | - 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 Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA; Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, 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, 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
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, 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
| | - 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 Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; 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, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT, 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
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health, Delaware 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, 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, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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9
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Wernovsky G, Ozturk M, Diddle JW, Muñoz R, d'Udekem Y, Yerebakan C. Rapid bilateral pulmonary artery banding: A developmentally based proposal for the management of neonates with hypoplastic left heart. JTCVS Open 2023; 14:398-406. [PMID: 37425468 PMCID: PMC10328842 DOI: 10.1016/j.xjon.2023.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Gil Wernovsky
- Division of Cardiology, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Mahmut Ozturk
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - J. Wesley Diddle
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Ricardo Muñoz
- Division of Cardiac Critical Care, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Can Yerebakan
- Division of Cardiac Surgery, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
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10
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Fink EL, Kochanek PM, Beers SR, Clark RRSB, Berger RP, Bayir H, Topjian AA, Newth C, Press C, Maddux AB, Willyerd F, Hunt EA, Siems A, Chung MG, Smith L, Doughty L, Diddle JW, Patregnani J, Piantino J, Walson KH, Balakrishnan B, Meyer MT, Friess S, Pineda J, Maloney D, Rubin P, Haller TL, Treble-Barna A, Wang C, Lee V, Wisnowski JL, Subramanian S, Narayanan S, Blüml S, Fabio A, Panigrahy A. Assessment of Brain Magnetic Resonance and Spectroscopy Imaging Findings and Outcomes After Pediatric Cardiac Arrest. JAMA Netw Open 2023; 6:e2320713. [PMID: 37389874 PMCID: PMC10314315 DOI: 10.1001/jamanetworkopen.2023.20713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/28/2023] [Indexed: 07/01/2023] Open
Abstract
Importance Morbidity and mortality after pediatric cardiac arrest are chiefly due to hypoxic-ischemic brain injury. Brain features seen on magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) after arrest may identify injury and aid in outcome assessments. Objective To analyze the association of brain lesions seen on T2-weighted MRI and diffusion-weighted imaging and N-acetylaspartate (NAA) and lactate concentrations seen on MRS with 1-year outcomes after pediatric cardiac arrest. Design, Setting, and Participants This multicenter cohort study took place in pediatric intensive care units at 14 US hospitals between May 16, 2017, and August 19, 2020. Children aged 48 hours to 17 years who were resuscitated from in-hospital or out-of-hospital cardiac arrest and who had a clinical brain MRI or MRS performed within 14 days postarrest were included in the study. Data were analyzed from January 2022 to February 2023. Exposure Brain MRI or MRS. Main Outcomes and Measures The primary outcome was an unfavorable outcome (either death or survival with a Vineland Adaptive Behavior Scales, Third Edition, score of <70) at 1 year after cardiac arrest. MRI brain lesions were scored according to region and severity (0 = none, 1 = mild, 2 = moderate, 3 = severe) by 2 blinded pediatric neuroradiologists. MRI Injury Score was a sum of T2-weighted and diffusion-weighted imaging lesions in gray and white matter (maximum score, 34). MRS lactate and NAA concentrations in the basal ganglia, thalamus, and occipital-parietal white and gray matter were quantified. Logistic regression was performed to determine the association of MRI and MRS features with patient outcomes. Results A total of 98 children, including 66 children who underwent brain MRI (median [IQR] age, 1.0 [0.0-3.0] years; 28 girls [42.4%]; 46 White children [69.7%]) and 32 children who underwent brain MRS (median [IQR] age, 1.0 [0.0-9.5] years; 13 girls [40.6%]; 21 White children [65.6%]) were included in the study. In the MRI group, 23 children (34.8%) had an unfavorable outcome, and in the MRS group, 12 children (37.5%) had an unfavorable outcome. MRI Injury Scores were higher among children with an unfavorable outcome (median [IQR] score, 22 [7-32]) than children with a favorable outcome (median [IQR] score, 1 [0-8]). Increased lactate and decreased NAA in all 4 regions of interest were associated with an unfavorable outcome. In a multivariable logistic regression adjusted for clinical characteristics, increased MRI Injury Score (odds ratio, 1.12; 95% CI, 1.04-1.20) was associated with an unfavorable outcome. Conclusions and Relevance In this cohort study of children with cardiac arrest, brain features seen on MRI and MRS performed within 2 weeks after arrest were associated with 1-year outcomes, suggesting the utility of these imaging modalities to identify injury and assess outcomes.
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Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert R. S. B. Clark
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel P. Berger
- Department of Pediatrics, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hülya Bayir
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Craig Press
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Aline B. Maddux
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora
| | | | - Elizabeth A. Hunt
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Ashley Siems
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Melissa G. Chung
- Department of Pediatrics, Division of Critical Care Medicine, and Pediatric Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lincoln Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Leslie Doughty
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - J. Wesley Diddle
- Department of Pediatrics, Children’s National Medical Center, Washington, DC
| | - Jason Patregnani
- Department of Pediatrics, Children’s National Medical Center, Washington, DC
| | - Juan Piantino
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Binod Balakrishnan
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Michael T. Meyer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
| | - Stuart Friess
- Department of Pediatrics, St Louis Children’s Hospital, St Louis, Missouri
| | - Jose Pineda
- Department of Anesthesia Critical Care, Mattel Children’s Hospital, University of California, Los Angeles
| | - David Maloney
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pamela Rubin
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tamara L. Haller
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amery Treble-Barna
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chunyan Wang
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vince Lee
- Department of Radiology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica L. Wisnowski
- Department of Radiology, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Subramanian Subramanian
- Department of Radiology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Srikala Narayanan
- Department of Radiology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stefan Blüml
- Department of Radiology, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Radiology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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11
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Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Michael Dean J, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, KirkpatrickN T, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Qunibi D, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes. Resuscitation 2023; 185:109673. [PMID: 36565948 PMCID: PMC10065910 DOI: 10.1016/j.resuscitation.2022.109673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
AIM To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit. METHODS This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses. RESULTS Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency. CONCLUSIONS Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Theresa KirkpatrickN
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Danna Qunibi
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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Neumayr TM, Alten JA, Bailly DK, Bhat PN, Brandewie KL, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Raymond TT, Reichle G, Zang H, Selewski DT. Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatr Nephrol 2023; 38:1355-1364. [PMID: 36066771 DOI: 10.1007/s00467-022-05697-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population. METHODS Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database. RESULTS Forty-five percent (n = 998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (- 15.4-40.4%). CONCLUSIONS Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Jeffrey A Alten
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Katie L Brandewie
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | | | - Huaiyu Zang
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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13
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Berg RA, Morgan RW, Reeder RW, 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, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med 2023; 51:91-102. [PMID: 36519983 PMCID: PMC9970166 DOI: 10.1097/ccm.0000000000005715] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort. DESIGN Prospective observational study. SETTING Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020. PATIENTS Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051). CONCLUSIONS These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.
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Affiliation(s)
- Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Bailly DK, Alten JA, Gist KM, Mah KE, Kwiatkowski DM, Valentine KM, Diddle JW, Tadphale S, Clarke S, Selewski DT, Banerjee M, Reichle G, Lin P, Gaies M, Blinder JJ. Fluid Accumulation After Neonatal Congenital Cardiac Operation: Clinical Implications and Outcomes. Ann Thorac Surg 2022; 114:2288-2294. [PMID: 35245511 PMCID: PMC9433462 DOI: 10.1016/j.athoracsur.2021.12.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study was conducted to determine the association between fluid balance metrics and mortality and other postoperative outcomes after neonatal cardiac operation in a contemporary multicenter cohort. METHODS This was an observational cohort study across 22 hospitals in neonates (≤30 days) undergoing cardiac operation. We explored overall percentage fluid overload, postoperative day 1 percentage fluid overload, peak percentage fluid overload, and time to first negative daily fluid balance. The primary outcome was in-hospital mortality. Secondary outcomes included postoperative duration of mechanical ventilation and intensive care unit (ICU) and hospital length of stay. Multivariable logistic or negative binomial regression was used to determine independent associations between fluid overload variables and each outcome. RESULTS The cohort included 2223 patients. In-hospital mortality was 3.9% (n = 87). Overall median peak percentage fluid overload was 4.9% (interquartile range, 0.4%-10.5%). Peak percentage fluid overload and postoperative day 1 percentage fluid overload were not associated with primary or secondary outcomes. Hospital resource utilization increased on each successive day of not achieving a first negative daily fluid balance and was characterized by longer duration of mechanical ventilation (incidence rate ratio, 1.11; 95% CI, 1.08-1.14), ICU length of stay (incidence rate ratio, 1.08; 95% CI, 1.03-1.12), and hospital length of stay (incidence rate ratio, 1.09; 95% CI, 1.05-1.13). CONCLUSIONS Time to first negative daily fluid balance, but not percentage fluid overload, is associated with improved postoperative outcomes in neonates after cardiac operation. Specific treatments to achieve an early negative fluid balance may decrease postoperative care durations.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.
| | - Jeffrey A Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katja M Gist
- Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David M Kwiatkowski
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Kevin M Valentine
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Sachin Tadphale
- Department of Pediatrics, University of Tennessee College of Medicine, Le Bonheur Children's Hospital, Memphis Tennessee
| | - Shanelle Clarke
- Department of Pediatrics, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - David T Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Garrett Reichle
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Paul Lin
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Michael Gaies
- Pediatric Cardiac Critical Care Consortium, Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Department of Anesthesia/Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Cashen K, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fink EL, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Meert KL. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med 2022; 23:784-792. [PMID: 35880872 PMCID: PMC9529841 DOI: 10.1097/pcc.0000000000003045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). DESIGN Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. SETTING Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). CONCLUSIONS In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Aisha H Frazier
- Department of Pediatrics, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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Fink EL, Kochanek PM, Panigrahy A, Beers SR, Berger RP, Bayir H, Pineda J, Newth C, Topjian AA, Press CA, Maddux AB, Willyerd F, Hunt EA, Siems A, Chung MG, Smith L, Wenger J, Doughty L, Diddle JW, Patregnani J, Piantino J, Walson KH, Balakrishnan B, Meyer MT, Friess S, Maloney D, Rubin P, Haller TL, Treble-Barna A, Wang C, Clark RRSB, Fabio A. Association of Blood-Based Brain Injury Biomarker Concentrations With Outcomes After Pediatric Cardiac Arrest. JAMA Netw Open 2022; 5:e2230518. [PMID: 36074465 PMCID: PMC9459665 DOI: 10.1001/jamanetworkopen.2022.30518] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Families and clinicians have limited validated tools available to assist in estimating long-term outcomes early after pediatric cardiac arrest. Blood-based brain-specific biomarkers may be helpful tools to aid in outcome assessment. OBJECTIVE To analyze the association of blood-based brain injury biomarker concentrations with outcomes 1 year after pediatric cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS The Personalizing Outcomes After Child Cardiac Arrest multicenter prospective cohort study was conducted in pediatric intensive care units at 14 academic referral centers in the US between May 16, 2017, and August 19, 2020, with the primary investigators blinded to 1-year outcomes. The study included 120 children aged 48 hours to 17 years who were resuscitated after cardiac arrest, had pre-cardiac arrest Pediatric Cerebral Performance Category scores of 1 to 3 points, and were admitted to an intensive care unit after cardiac arrest. EXPOSURE Cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was an unfavorable outcome (death or survival with a Vineland Adaptive Behavior Scales, third edition, score of <70 points) at 1 year after cardiac arrest. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCH-L1), neurofilament light (NfL), and tau concentrations were measured in blood samples from days 1 to 3 after cardiac arrest. Multivariate logistic regression and area under the receiver operating characteristic curve (AUROC) analyses were performed to examine the association of each biomarker with outcomes on days 1 to 3. RESULTS Among 120 children with primary outcome data available, the median (IQR) age was 1.0 (0-8.5) year; 71 children (59.2%) were male. A total of 5 children (4.2%) were Asian, 19 (15.8%) were Black, 81 (67.5%) were White, and 15 (12.5%) were of unknown race; among 110 children with data on ethnicity, 11 (10.0%) were Hispanic, and 99 (90.0%) were non-Hispanic. Overall, 70 children (58.3%) had a favorable outcome, and 50 children (41.7%) had an unfavorable outcome, including 43 deaths. On days 1 to 3 after cardiac arrest, concentrations of all 4 measured biomarkers were higher in children with an unfavorable vs a favorable outcome at 1 year. After covariate adjustment, NfL concentrations on day 1 (adjusted odds ratio [aOR], 5.91; 95% CI, 1.82-19.19), day 2 (aOR, 11.88; 95% CI, 3.82-36.92), and day 3 (aOR, 10.22; 95% CI, 3.14-33.33); UCH-L1 concentrations on day 2 (aOR, 11.27; 95% CI, 3.00-42.36) and day 3 (aOR, 7.56; 95% CI, 2.11-27.09); GFAP concentrations on day 2 (aOR, 2.31; 95% CI, 1.19-4.48) and day 3 (aOR, 2.19; 95% CI, 1.19-4.03); and tau concentrations on day 1 (aOR, 2.44; 95% CI, 1.14-5.25), day 2 (aOR, 2.28; 95% CI, 1.31-3.97), and day 3 (aOR, 2.04; 95% CI, 1.16-3.57) were associated with an unfavorable outcome. The AUROC models were significantly higher with vs without the addition of NfL on day 2 (AUROC, 0.932 [95% CI, 0.877-0.987] vs 0.871 [95% CI, 0.793-0.949]; P = .02) and day 3 (AUROC, 0.921 [95% CI, 0.857-0.986] vs 0.870 [95% CI, 0.786-0.953]; P = .03). CONCLUSIONS AND RELEVANCE In this cohort study, blood-based brain injury biomarkers, especially NfL, were associated with an unfavorable outcome at 1 year after pediatric cardiac arrest. Additional evaluation of the accuracy of the association between biomarkers and neurodevelopmental outcomes beyond 1 year is needed.
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Affiliation(s)
- Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sue R. Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel P. Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hülya Bayir
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Children’s Neuroscience Institute, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jose Pineda
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Christopher Newth
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia
| | - Craig A. Press
- Department of Pediatrics and Neurology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia
| | - Aline B. Maddux
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
| | | | - Elizabeth A. Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Ashley Siems
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
- Department of Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Melissa G. Chung
- Department of Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lincoln Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Jesse Wenger
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lesley Doughty
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - J. Wesley Diddle
- Department of Pediatrics, Children’s National Hospital, District of Columbia
| | - Jason Patregnani
- Department of Pediatrics, Barbara Bush Children’s Hospital, Portland, Maine
| | - Juan Piantino
- Department of Pediatrics, Oregon Health & Science University, Portland
| | | | - Binod Balakrishnan
- Department of Pediatrics, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Michael T. Meyer
- Department of Pediatrics, Children’s Wisconsin, Medical College of Wisconsin, Milwaukee
| | - Stuart Friess
- Department of Pediatrics, St Louis Children’s Hospital, St Louis, Missouri
| | - David Maloney
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pamela Rubin
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tamara L. Haller
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amery Treble-Barna
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Chunyan Wang
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert R. S. B. Clark
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, Franzon D, Frazier AH, Friess SH, Graham K, Hehir D, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, Morgan RW, Nadkarni VM, Naim MY, Palmer CA, Schneiter C, Sharron MP, Siems A, Srivastava N, Tabbutt S, Tilford B, Viteri S, Berg RA, Bell MJ, Carcillo JA, Carpenter TC, Dean JM, Fink EL, Hall M, McQuillen PS, Meert KL, Mourani PM, Notterman D, Pollack MM, Sapru A, Wessel D, Yates AR, Zuppa AF. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA 2022; 327:934-945. [PMID: 35258533 PMCID: PMC8905390 DOI: 10.1001/jama.2022.1738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. OBJECTIVE To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings. DESIGN, SETTING, AND PARTICIPANTS A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021). INTERVENTION During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge. RESULTS Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47). CONCLUSIONS AND RELEVANCE In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02837497.
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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
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Aisha H Frazier
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - David Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Ashley Siems
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Michael J Bell
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
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