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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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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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3
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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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4
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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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5
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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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6
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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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7
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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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8
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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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9
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Reeder RW, Girling A, Wolfe H, Holubkov R, Berg RA, Naim MY, Meert KL, Tilford B, Carcillo JA, Hamilton M, Bochkoris M, Hall M, Maa T, Yates AR, Sapru A, Kelly R, Federman M, Michael Dean J, McQuillen PS, Franzon D, Pollack MM, Siems A, Diddle J, Wessel DL, Mourani PM, Zebuhr C, Bishop R, Friess S, Burns C, Viteri S, Hehir DA, Whitney Coleman R, Jenkins TL, Notterman DA, Tamburro RF, Sutton RM. Improving outcomes after pediatric cardiac arrest - the ICU-Resuscitation Project: study protocol for a randomized controlled trial. Trials 2018; 19:213. [PMID: 29615134 PMCID: PMC5883604 DOI: 10.1186/s13063-018-2590-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 03/12/2018] [Indexed: 12/22/2022] Open
Abstract
Background Quality of cardiopulmonary resuscitation (CPR) is associated with survival, but recommended guidelines are often not met, and less than half the children with an in-hospital arrest will survive to discharge. A single-center before-and-after study demonstrated that outcomes may be improved with a novel training program in which all pediatric intensive care unit staff are encouraged to participate in frequent CPR refresher training and regular, structured resuscitation debriefings focused on patient-centric physiology. Methods/design This ongoing trial will assess whether a program of structured debriefings and point-of-care bedside practice that emphasizes physiologic resuscitation targets improves the rate of survival to hospital discharge with favorable neurologic outcome in children receiving CPR in the intensive care unit. This study is designed as a hybrid stepped-wedge trial in which two of ten participating hospitals are randomly assigned to enroll in the intervention group and two are assigned to enroll in the control group for the duration of the trial. The remaining six hospitals enroll initially in the control group but will transition to enrolling in the intervention group at randomly assigned staggered times during the enrollment period. Discussion To our knowledge, this is the first implementation of a hybrid stepped-wedge design. It was chosen over a traditional stepped-wedge design because the resulting improvement in statistical power reduces the required enrollment by 9 months (14%). However, this design comes with additional challenges, including logistics of implementing an intervention prior to the start of enrollment. Nevertheless, if results from the single-center pilot are confirmed in this trial, it will have a profound effect on CPR training and quality improvement initiatives. Trial registration ClinicalTrials.gov, NCT02837497. Registered on July 19, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2590-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Alan Girling
- The Learning Centre Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Robert A Berg
- 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
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melinda Hamilton
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Anil Sapru
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert Kelly
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - Myke Federman
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - Ashley Siems
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - John Diddle
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - David L Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Peter M Mourani
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Carleen Zebuhr
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Robert Bishop
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Stuart Friess
- Department of Pediatrics, Washington University Medical Center, St. Louis, MO, USA
| | - Candice Burns
- Department of Pediatrics, Washington University Medical Center, St. Louis, MO, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - David A Hehir
- Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - R Whitney Coleman
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Tammara L Jenkins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Daniel A Notterman
- Department of Pediatrics, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, PA, USA
| | - Robert F Tamburro
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 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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Abstract
OBJECTIVE The objective of this study was to determine the impact of family-centered multidisciplinary rounds on an inpatient pediatric ward. We hoped to (1) gain a better understanding of the patient and family experience with family-centered multidisciplinary rounds, (2) measure hospital staff satisfaction with family-centered multidisciplinary rounds compared with conventional rounds, and (3) understand the time commitment for family-centered multidisciplinary rounds and conventional rounds. METHODS A quasi-experimental design was undertaken during a 2-week period. During the first week, the hospital staff conducted conventional rounds. Families were surveyed daily, and the staff were surveyed at the end of the week regarding their experiences. During the second week, newly admitted patients received family-centered multidisciplinary rounds at the bedside. Again, both families and staff were surveyed. Observers recorded the interactions between families and staff and measured the time required to conduct rounds. RESULTS A total of 27 patients were admitted during the 2-week study period. No significant differences were found in family satisfaction between conventional rounds and family-centered multidisciplinary rounds. A total of 53 surveys were collected from staff members. The staff reported better understanding of the patients' medical plans, better ability to help the families, and a greater sense of teamwork with family-centered multidisciplinary rounds compared with conventional rounds. It required an additional 2.7 minutes per patient during rounds for family-centered multidisciplinary rounds. With family-centered multidisciplinary rounds, the family affected the medical decision-making discussion in 90% of cases. CONCLUSIONS Family-centered multidisciplinary rounds is a method of conducting inpatient hospital rounds that fosters teamwork and empowers hospital staff. The patient and family are engaged in and are the focal point of the rounds. Staff members are able to hear everyone's perspective and give input. The impact on staff satisfaction and the family's ability to participate in their care is significant.
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Affiliation(s)
- Paul Rosen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15201, USA.
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