Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation

AIM

This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival.

METHODS

Data from the German Resuscitation Registry (GRR) were used, and we included patients registered between 1st January 2007 and 31st December 2021. We included children aged between > 7 days and 17 years, where cardiopulmonary resuscitation (CPR) was started, and treatment was continued by emergency medical services (EMS). Incidences and descriptive analyses are presented for the overall cohort and each age group. Multivariate binary logistic regression was performed on the whole cohort to determine the influence of (1) CPR with/without ventilation started by bystander, (2) OHCA witnessed status and (3) night-time on the outcome hospital admission with return of spontaneous circulation (ROSC).

RESULTS

OHCA in children aged < 1 year had the highest incidence of the same age group, with 23.42 per 100 000. Overall, hypoxia was the leading presumed cause of OHCA, whereas trauma and drowning accounted for a high proportion in children aged > 1 year. Bystander-witnessed OHCA and bystander CPR rate were highest in children aged 1-4 years, with 43.9% and 62.3%, respectively. In reference to EMS-started CPR, bystander CPR with ventilation were associated with an increased odds ratio for ROSC at hospital admission after adjusting for age, sex, year of OHCA and location of OHCA.

CONCLUSION

This study provides an epidemiological overview of OHCA in children in Germany and identifies bystander CPR with ventilation as one primary factor for survival. Trial registrations German Clinical Trial Register: DRKS00030989, December 28th 2022.

Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine

Aim

To evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO₂) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine.

Methods

Swine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO₂-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO₂-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO₂ was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO₂ remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared.

Results

Short-term survival was significantly greater in the ETCO₂-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO₂, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups.

Conclusions

Use of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO₂ level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.

Therapeutic hypothermia after paediatric cardiac arrest: Pooled randomized controlled trials

BACKGROUND

Separate trials to evaluate therapeutic hypothermia after paediatric cardiac arrest for out-of-hospital and in-hospital settings reported no statistically significant differences in survival with favourable neurobehavioral outcome or safety compared to therapeutic normothermia. However, larger sample sizes might detect smaller clinical effects. Our aim was to pool data from identically conducted trials to approximately double the sample size of the individual trials yielding greater statistical power to compare outcomes.

METHODS

Combine individual patient data from two clinical trials set in forty-one paediatric intensive care units in USA, Canada and UK. Children aged at least 48 h up to 18 years old, who remained comatose after resuscitation, were randomized within 6 h of return of circulation to hypothermia or normothermia (target 33.0 °C or 36.8 °C). The primary outcome, survival 12 months post-arrest with Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score at least 70 (scored from 20 to 160, higher scores reflecting better function, population mean = 100, SD = 15), was evaluated among patients with pre-arrest scores ≥70.

RESULTS

624 patients were randomized. Among 517 with pre-arrest VABS-II scores ≥70, the primary outcome did not significantly differ between hypothermia and normothermia groups (28% [75/271] and 26% [63/246], respectively; relative risk, 1.08; 95% confidence interval [CI], 0.81 to 1.42; p = 0.61). Among 602 evaluable patients, the change in VABS-II score from baseline to 12 months did not differ significantly between groups (p = 0.20), nor did, proportion of cases with declines no more than 15 points or improvement from baseline [22% (hypothermia) and 21% (normothermia)]. One-year survival did not differ significantly between hypothermia and normothermia groups (44% [138/317] and 38% [113/ 297], respectively; relative risk, 1.15; 95% CI, 0.95 to 1.38; p = 0.15). Incidences of blood-product use, infection, and serious cardiac arrhythmia adverse events, and 28-day mortality, did not differ between groups.

CONCLUSIONS

Analysis of combined data from two paediatric cardiac arrest targeted temperature management trials including both in-hospital and out-of-hospital cases revealed that hypothermia, as compared with normothermia, did not confer a significant benefit in survival with favourable functional outcome at one year.

Resuscitation registers: How many active registers are there and how many collect data on paediatric cardiac arrests?

BACKGROUND

Cardiac arrest, particularly in children, often has a poor outcome and international guidelines highlight significant gaps in the evidence base for effective resuscitation. Whilst randomised controlled trials for some interventions can be justified, they are not appropriate for many aspects of resuscitation. Therefore, guidelines must use other sources of data such as epidemiological evidence from cardiac arrest registries, to improve the efficacy of resuscitation. The aim of our study was to identify existing national cardiac arrest registries and document key information about the registries, including whether they contain data on paediatric arrests.

METHODS

Key bibliographic databases were searched for papers about or using data from cardiac arrest registries. Two reviewers independently screened the search results for relevant papers. A list of registers named in the papers was compiled and information obtained from the papers and the websites of registers where possible.

RESULTS

Twenty three active national or large regional cardiac arrest registries were identified. These included five international collaborations and 10 registries that cover a population of at least 10 million people. Twelve registries are based in Europe, five in North America, four in Asia and two in Australasia. The registries vary in their organisation, but the majority (20) defer to the Utstein reporting guidelines for cardiac arrest. Registries covered populations between 0.4 and 174.5 million and contained between 100 and 605,505 records. Sixteen collected data on out-of-hospital arrests only; three in-hospital arrests only; and four included both. For ten registers the number of paediatric arrests was available and ranged from 56 to 3900.

CONCLUSIONS

To our knowledge this report contains the most complete list of active national and large regional cardiac arrest registries. Register data support current guidelines on effective resuscitation however, even the largest registries include relatively small numbers, particularly of paediatric events. A less fragmented approach has the potential to improve the utility of registration data for the benefit of patients.

Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation

AIM

To investigate if the serum biomarkers of cerebral injury, neuron-specific enolase and S100b protein, may classify unfavourable neurological outcome after paediatric cardiac arrest.

METHODS

We performed a retrospective study of neuron-specific enolase and S100b measurements from 95 children treated in our paediatric cardiac intensive care unit after cardiac arrest. Neurological outcome at discharge was evaluated using the paediatric cerebral performance category scale, with unfavourable outcome defined as a change of >1 compared to pre-arrest status or death.

RESULTS

Fifty-eight patients (61.1%) survived to discharge with 48 (50.5%) having a favourable neurological outcome. We observed significantly higher levels of both biomarkers in the unfavourable outcome group at designated time points (neuron-specific enolase at 24, 48, and 72h and S100b at 12, 24, and 48h after cardiac arrest, p<0.05). Receiver operating characteristic areas under the curve for neuron-specific enolase were 0.83, 0.80, and 0.73 at time points 24, 48, and 72h and 0.87, 0.81, and 0.82 for S100b at 12, 24, and 48h after cardiac arrest, respectively. Neuron-specific enolase measurement at 24h after cardiac arrest was an independent predictor of unfavourable outcome in a multivariable analysis.

CONCLUSIONS

Neuron-specific enolase and S100b classify unfavourable neurological outcome in this large paediatric cardiac arrest cohort. Further multi-institutional prospective studies to comprehensively evaluate the diagnostic accuracy of these biomarkers under various clinical conditions and to determine reliable cut-off values in children are warranted.