Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest

BACKGROUND

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes.

METHODS

In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes.

RESULTS

We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes.

CONCLUSIONS

Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA).

DESIGN

Retrospective cohort study.

SETTING

An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q].

PATIENTS

All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100-149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately.

CONCLUSIONS

The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.

Poor Concordance of One-Third Anterior-Posterior Chest Diameter Measurements With Absolute Age-Specific Chest Compression Depth Targets in Pediatric Cardiac Arrest Patients

Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one-third anterior-posterior diameter (APD), which is presumed to equate to absolute age-specific chest compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumption. We aimed to study the concordance of measured one-third APD with absolute age-specific chest compression depth targets in a cohort of pediatric patients with cardiac arrest. Methods and Results This was a retrospective observational study from a multicenter, pediatric resuscitation quality collaborative (pediRES-Q [Pediatric Resuscitation Quality Collaborative]) from October 2015 to March 2022. In-hospital patients with cardiac arrest ≤12 years old with APD measurements recorded were included for analysis. One hundred eighty-two patients (118 infants >28 days old to <1 year old, and 64 children 1 to 12 years old) were analyzed. The mean one-third APD of infants was 3.2 cm (SD, 0.7 cm), which was significantly smaller than the 4 cm target depth (P<0.001). Seventeen percent of the infants had one-third APD measurements within the 4 cm ±10% target range. For children, the mean one-third APD was 4.3 cm (SD, 1.1 cm). Thirty-nine percent of children had one-third APD within the 5 cm ±10% range. Except for children 8 to 12 years old and overweight children, the measured mean one-third APD of the majority of the children was significantly smaller than the 5 cm depth target (P<0.05). Conclusions There was poor concordance between measured one-third APD and absolute age-specific chest compression depth targets, particularly for infants. Further study is needed to validate current pediatric chest compression depth targets and evaluate the optimal chest compression depth to improve cardiac arrest outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.

Paediatric In-hospital cardiopulmonary resuscitation quality and outcomes in children with CHD during nights and weekends

BACKGROUND

Survival after paediatric in-hospital cardiac arrest is worse on nights and weekends without demonstration of disparity in cardiopulmonary resuscitation quality. It is unknown whether these findings differ in children with CHD. This study aimed to determine whether cardiopulmonary resuscitation quality might explain the hypothesised worse outcomes of children with CHD during nights and weekends.

METHODS

In-hospital cardiac arrest data collected by the Pediatric Resuscitation Quality Collaborative for children with CHD. Chest compression quality metrics and survival outcomes were compared between events that occurred during day versus night, and during weekday versus weekend using multivariable logistic regression.

RESULTS

We evaluated 3614 sixty-second epochs of chest compression data from 132 subjects between 2015 and 2020. There was no difference in chest compression quality metrics during day versus night or weekday versus weekend. Weekday versus weekend was associated with improved survival to hospital discharge (adjusted odds ratio 4.56 [1.29,16.11]; p = 0.02] and survival to hospital discharge with favourable neurological outcomes (adjusted odds ratio 6.35 [1.36,29.6]; p = 0.02), but no difference with rate of return of spontaneous circulation or return of circulation. There was no difference in outcomes for day versus night.

CONCLUSION

For children with CHD and in-hospital cardiac arrest, there was no difference in chest compression quality metrics by time of day or day of week. Although there was no difference in outcomes for events during days versus nights, there was improved survival to hospital discharge and survival to hospital discharge with favourable neurological outcome for events occurring on weekdays compared to weekends.

Risk factors and outcomes for recurrent paediatric in-hospital cardiac arrest: Retrospective multicenter cohort study

AIM OF STUDY

Recurrent in-hospital cardiac arrest (IHCA) is associated with morbidity and mortality in adults. We aimed to describe the risk factors and outcomes for paediatric recurrent IHCA.

METHODS

Retrospective cohort study of patients ≤18 years old with single or recurrent IHCA. Recurrent IHCA was defined as ≥2 IHCA within the same hospitalization. Categorical variables expressed as percentages and compared via Chi square test. Continuous variables expressed as medians with interquartile ranges and compared via rank sum test. Outcomes assessed in a propensity match cohort.

RESULTS

From July 1, 2015 to January 26, 2021, 139/894 (15.5%) patients experienced recurrent IHCA. Compared to patients with a single IHCA, recurrent IHCA patients were more likely to be trauma and less likely to be surgical cardiac patients. Median duration of cardiopulmonary resuscitation (CPR) was shorter in the recurrent IHCA (5 vs. 11 min; p < 0.001) with no difference in IHCA location or immediate cause of CPR. Patients with recurrent IHCA had worse survival to intensive care unit (ICU) discharge (31% vs. 52%; p < 0.001), and worse survival to hospital discharge (30% vs. 48%; p < 0.001) in unadjusted analyses and after propensity matching, patients with recurrent IHCA still had worse survival to ICU (34% vs. 67%; p < 0.001) and hospital (31% vs. 64%; p < 0.001) discharge.

CONCLUSION

When examining those with a single vs. a recurrent IHCA, event and patient factors including more pre-existing conditions and shorter duration of CPR were associated with risk for recurrent IHCA. Recurrent IHCA is associated with worse survival outcomes following propensity matching.

Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative

OBJECTIVES

Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative.

METHODS

From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated.

RESULTS

All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions.

CONCLUSIONS

Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.

Effect of Amplitude Spectral Area on Termination of Fibrillation and Outcomes in Pediatric Cardiac Arrest

Background

Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and survival in adults but has not been studied in pediatric cardiac arrest. We characterized AMSA during pediatric cardiac arrest from a Pediatric Resuscitation Quality Collaborative and hypothesized that AMSA would be associated with TOF and ROSC.

Methods and Results

Children aged <18 years with cardiac arrest and ventricular fibrillation were studied. AMSA was calculated for 2 seconds before shock and averaged for each subject (AMSA‐avg). TOF was defined as termination of ventricular fibrillation 10 seconds after defibrillation to any non‐ventricular fibrillation rhythm. ROSC was defined as >20 minutes without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category were performed. Primary end points were TOF and ROSC. Secondary end points were 24‐hour survival and survival to discharge. Between 2015 and 2019, 50 children from 14 hospitals with 111 shocks were identified. In univariate analyses AMSA was not associated with TOF and AMS‐Aavg was not associated with ROSC. Multivariable logistic regression showed no association between AMSA and TOF but controlling for defibrillation average current and illness category, there was a trend to significant association between AMSA‐avg and ROSC (odds ratio, 1.10 [1.00‒1.22] P=0.058). There was no significant association between AMSA‐avg and 24‐hour survival or survival to hospital discharge.

Conclusions

In pediatric patients, AMSA was not associated with TOF, whereas AMSA‐avg had a trend to significance for association in ROSC, but not 24‐hour survival or survival to hospital discharge.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.

Simulating blood pressure and end tidal CO2 in a CPR training manikin

BACKGROUND AND OBJECTIVE

The American Heart Association supports titrating the mechanics of cardiopulmonary resuscitation (CPR) to blood pressure and end tidal carbon dioxide (ETCO2) thresholds during in-hospital cardiac arrest. However, current CPR manikin training systems do not prepare clinicians to use these metrics to gauge their performance, and currently provide only feedback on hand placement, depth, rate, release, and interruptions of chest compressions. We addressed this training hardware deficiency through development of a novel CPR training manikin that displays simulated blood pressure and ETCO2 waveforms in real time on a simulated clinical monitor visible to the learner, reflecting the mechanics of chest compressions provided to the manikin. Such a manikin could improve clinicians' CPR technique while also training them to titrate CPR quality to physiologic blood pressure and ETCO2 targets as performance indicators.

METHODS

We used data and key findings from 4 human and 6 animal studies (including 132 human subjects, 61 pigs, and 16 dogs in total) to develop an algorithm that simulates blood pressure and ETCO2 waveforms based on compression mechanics for a pediatric patient. We modified an off-the-shelf infant manikin to incorporate a microcontroller sufficient to process the aforementioned algorithm, and a tablet computer to wirelessly display the simulated waveform. We recruited clinicians with in-hospital CPR experience to perform compressions with the manikin and complete a post-test survey on their satisfaction with designated elements of the manikin and display.

RESULTS

34 clinicians performed CPR on the prototype manikin system that simulates real-time bedside monitoring of blood pressure and ETCO2. 100% of clinicians surveyed reported "satisfaction" with the blood pressure waveform. 97% said they thought depth was accurately reflected in blood pressure (0% inaccurate, 3% not sure). 88% reported an accurate chest compression rate modification effect on blood pressure and ETCO2 (3% inaccurate, 9% not sure) and 59% an accurate effect of leaning (6% inaccurate, 35% not sure). Most importantly, all 34 respondents responded "yes" when asked if they thought this system would be helpful for CPR training.

CONCLUSION

A CPR manikin that simulates blood pressure and ETCO2 was successfully developed with acceptable relevance, performance and feasibility as a CPR quality training tool.

Rhythm characteristics and patterns of change during cardiopulmonary resuscitation for in-hospital paediatric cardiac arrest

During paediatric cardiopulmonary resuscitation (CPR), patients may transition between pulseless electrical activity (PEA), asystole, ventricular fibrillation/tachycardia (VF/VT), and return of spontaneous circulation (ROSC). The aim of this study was to quantify the dynamic characteristics of this process.

METHODS

ECG recordings were collected in patients who received CPR at the Children's Hospital of Philadelphia (CHOP) between 2006 and 2013. Transitions between PEA (including bradycardia with poor perfusion), VF/VT, asystole, and ROSC were quantified by applying a multi-state statistical model with competing risks, and by smoothing the Nelson-Aalen estimator of cumulative hazard.

RESULTS

Seventy-four episodes of cardiac arrest were included. Median age of patients was 15 years [IQR 11-17], 50% were female and 62% had a respiratory aetiology of arrest. Presenting cardiac arrest rhythms were PEA (60%), VF/VT (24%) and asystole (16%). A temporary surge of PEA was observed between 10 and 15 min due to a doubling of the transition rate from ROSC to PEA (i.e. 're-arrests'). The prevalence of sustained ROSC reached an asymptotic value of 30% at 20 min. Simulation suggests that doubling the transition rate from PEA to ROSC and halving the relapse rate might increase the prevalence of sustained ROSC to 50%.

CONCLUSION

Children and adolescents who received CPR were prone to re-arrest between 10 and 15 min after start of CPR efforts. If the rate of PEA to ROSC transition could be increased and the rate of re-arrests reduced, the overall survival rate may improve.

Video performance-debriefings and ventilation-refreshers improve quality of neonatal resuscitation

AIM

Providers caring for newly born infants require skills and knowledge to initiate prompt and effective positive pressure ventilation (PPV) if the newborn does not breathe spontaneously after birth. We hypothesized implementation of high frequency/short duration deliberate practice training and post event video-based debriefings would improve process of care and decreases time to effective spontaneous respiration.

METHODS

Pre- and post-interventional quality study performed at two Norwegian university hospitals. All newborns receiving PPV were prospectively video-recorded, and initial performance data guided the development of educational interventions. A priori primary outcome was changed from process of care using the Neonatal Resuscitation Performance Evaluation (NRPE) score to time to effective spontaneous respiration as the NRPE score could only be obtained from one site due to lack of staff resources.

RESULTS

Over 12 months, 297 PPV-Refreshers and 52 performance debriefings were completed with 227 unique providers attending a PPV-Refresher and 93 unique providers completed a debriefing. We compared 102 PPV-events pre- to 160 PPV-events post-bundle implementation. The time to effective spontaneous respiration decreased from median (95% confidence interval) 196 (140-237) to 144 (120-163) s, p = 0.010. The NRPE-score increased significantly from median 77% (75-81) pre- to 89% (86-92) post-implementation, p < 0.001. There were no significant differences in time to heart rate >100 beats/min or number of newborns transferred to intensive care.

CONCLUSION

High frequency/short duration deliberate practice PPV psychomotor training combined with performance-focused team debriefings using video recordings of actual resuscitations may improve time to effective spontaneous breathing and adherence to guidelines during real neonatal resuscitations.

Description of hot debriefings after in-hospital cardiac arrests in an international pediatric quality improvement collaborative

BACKGROUND

The American Heart Association recommends debriefing after attempted resuscitation from in-hospital cardiac arrest (IHCA) to improve resuscitation quality and outcomes. This is the first published study detailing the utilization, process and content of hot debriefings after pediatric IHCA.

METHODS

Using prospective data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q), we analyzed data from 227 arrests occurring between February 1, 2016, and August 31, 2017. Hot debriefings, defined as occurring within minutes to hours of IHCA, were evaluated using a modified Team Emergency Assessment Measure framework for qualitative content analysis of debriefing comments.

RESULTS

Hot debriefings were performed following 108 of 227 IHCAs (47%). The median interval to debriefing was 130 min (Interquartile range [IQR] 45, 270). Median debriefing duration was 15 min (IQR 10, 20). Physicians facilitated 95% of debriefings, with a median of 9 participants (IQR 7, 11). After multivariate analysis, accounting for hospital site, debriefing frequency was not associated with patient age, gender, race, illness category or unit type. The most frequent positive (plus) comments involved cooperation/coordination (60%), communication (47%) and clinical standards (41%). The most frequent negative (delta) comments involved equipment (46%), cooperation/coordination (45%), and clinical standards (36%).

CONCLUSION

Approximately half of pediatric IHCAs were followed by hot debriefings. Hot debriefings were multi-disciplinary, timely, and often addressed issues of team cooperation/coordination, communication, clinical standards, and equipment. Additional studies are warranted to identify barriers to hot debriefings and to evaluate the impact of these debriefings on patient outcomes.

Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital

INTRODUCTION

The Neonatal Resuscitation Program (NRP) guidelines recommend positive pressure ventilation (PPV) in the first 60s of life to support perinatal transition in non-breathing newborns. Our aim was to describe the incidence and characteristics of newborn PPV using real-time observation in the delivery unit.

METHODS

Prospective, observational, quality improvement study conducted at a tertiary academic hospital. Deliveries during randomized weekday/evening 8-h shifts were attended by a trained observer. Intervention data were recorded for all newborns with gestational age (GA) ≥34wks that received PPV. Descriptive summaries and Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables were used to compare characteristics.

RESULTS

Of 1135 live deliveries directly observed over 18mos, 64 (6%) newborns with a mean GA 39±2wks received PPV: Median time from birth to warmer was 20s (IQR 15-22s); PPV was initiated within 60s of life in 29 (45%) and between 60 and 90s of life in 17 (27%). PPV duration was <120s in 38 (60%). Seven/21 (33%) newborns that received PPV after vaginal delivery were not pre-identified and resuscitation team was alerted after delivery. We found no association between PPV start time and duration of PPV (p=0.86).

CONCLUSION

We observed that most (94%) term newborns spontaneously initiate respirations. In over half observed deliveries receiving PPV, time to initiation of PPV was greater than 60s (longer than recommended). Compliance with current NRP guidelines is difficult, and it's not clear whether it is the recommendations or the training to achieve PPV recommendations that should be modified.

Ventilation fraction during the first 30s of neonatal resuscitation

AIM

Approximately 5% of newborns receive positive pressure ventilation (PPV) for successful transition. Guidelines urge providers to ensure effective PPV for 30-60s before considering chest compressions and intravenous therapy. Pauses in this initial PPV may delay recovery of spontaneous respiration. The aim was to find the ventilation fraction during the first 30s of PPV in non-breathing babies.

METHODS

Prospective observational study in two hospitals in Norway. All newborns receiving PPV immediately after delivery were included. Cameras with motion detectors were installed at every resuscitation bay capturing both expected and unexpected compromised newborns. We determined the cumulative number of seconds with PPV efforts excluding pauses in infants without spontaneous breathing and reported ventilation fraction during the first minute. Data are presented as median (IQR).

RESULTS

110 of 3508 (3%) newborns received PPV and were filmed in the resuscitation bays. PPV started 42 (18-78)s after arrival at the resuscitation bay and median duration was 100 (35-225)s. Forty-eight infants (44%) were ventilated continuously, or with minimal pause (ventilation fraction >90%) during the first 30s of PPV. For the remaining 62 infants ventilation fraction was 60% (39-75). PPV was interrupted due to adjustments, checking heart rate, stimulation, administration of CPAP and suctioning.

CONCLUSION

In 56% of the neonatal resuscitations interruptions in ventilation are frequent with 60% ventilation fraction during the first 30s of PPV. Eliminating disruption for improved quality of PPV delivery should be emphasized when training newborn resuscitation providers.

Quantitative analysis of duty cycle in pediatric and adolescent in-hospital cardiac arrest

AIMS

Quality cardiopulmonary resuscitation (CPR) is associated with improved outcomes during cardiac arrest. Duty cycle (DC) represents an understudied element of CPR quality. Our objective was to quantitatively analyze DC during actual pediatric and adolescent in-hospital cardiac arrest (IHCA).

METHODS

Prospective observational study of IHCA at a large academic children's hospital. CPR variables included DC (%) up to the first 10min of recorded chest compressions (CCs). American Heart Association (AHA) DC compliance was prospectively defined as an average event DC of 50±5%. Percentage of events compliant with AHA DC was compared to a priori hypothesized compliance percentage of 25% using chi-square. Association between DC quartiles and categories of depth (<38, 38-49, ≥50mm) and rate (<100, 100-120, >120min(-1)) were analyzed by chi-square test for trend.

RESULTS

Between October 2006 and June 2015, 97 events in 87 patients were analyzed. Mean DC for events was 40±2.8%. DC quartiles: Q1 (DC ≤38.3%), Q2 (>38.3-40.1%), Q3 (>40.1-42.1%), Q4 (>42.1%). Only 5 (5.2%) events met AHA DC compliance, significantly less than the a priori hypothesis of 25% (p<0.001). Average CC rates trended higher across DC quartiles: (Q1) 105±9; (Q2) 106±9; (Q3) 112±8; and (Q4) 118±14min(-1); p<0.001. Other CPR quality variables were not associated with DC. There was no association between DC and survival.

CONCLUSIONS

Compression DC during resuscitation of actual child and adolescent IHCA met AHA recommendations in only 5% of events. In this series we found no association of DC with CC depth or survival.

Incidence of Newborn Stabilization and Resuscitation Measures and Guideline Compliance during the First Minutes of Life in Norway

BACKGROUND

Most newborns manage the transition from intra- to extrauterine life without interventions, yet neonatal morbidity caused by failure of transition remains an important health problem.

OBJECTIVE

To determine the incidence of neonatal stabilization and resuscitation measures and guideline compliance during the first minutes after birth.

METHODS

This is a prospective, observational study of all births in three Norwegian hospitals. All interventions performed, including suctioning, use of pulse oximetry, continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), supplemental oxygen, intubation, and administration of drugs, were registered at every on-call team shift during the study period.

RESULTS

A total of 1,507 live-born infants were included, of whom 264 (18%) were brought to the resuscitation crib. Oropharyngeal suctioning was performed in 77 (5%), deep blind suctioning was carried out in 10 (1%) and 84 (6%) were monitored using pulse oximetry. PPV was provided in 58 cases (4%) - 8 (21%) of <34 weeks and 50 (3%) of ≥34 weeks of gestation. Sustained inflation is not routinely used in these departments. CPAP (without PPV) was provided in 17 cases (1%) - 4 (0.3%) were intubated and ventilated through the endotracheal tube. Supplemental oxygen was given to 39 infants (3%) - 9 without pulse oximetry monitoring. The median (interquartile range) birth weight and gestational age of the newborns requiring PPV and/or CPAP were 3,220 g (2,643-3,858) and 39 weeks (37-41), respectively.

CONCLUSION

In this study, the need for resuscitation and/or stabilization measures was commonly considered, and 4% of all newborns received PPV. Despite strong guideline emphasis on the use of pulse oximetry to guide oxygen administration, many infants received oxygen treatment without pulse oximetry monitoring.

Simplified dispatcher instructions improve bystander chest compression quality during simulated pediatric resuscitation

AIM

Cardiopulmonary resuscitation (CPR) quality is associated with survival outcomes after out-of-hospital cardiac arrest. The objective of this study was to evaluate the effectiveness of simplified dispatcher CPR instructions to improve the chest compression (CC) quality during simulated pediatric cardiac arrest in public places.

METHODS

Adult bystanders recruited in public places were randomized to receive one of two scripted dispatcher CPR instructions: (1) "Push as hard as you can" (PUSH HARD) or (2) "Push approximately 2 inches" (TWO INCHES). A pediatric manikin with realistic CC characteristics (similar to a 6-year-old child), and a CPR recording defibrillator was used for quantitative CC data collection during a 2-min simulated pediatric scenario. The primary outcome was average CC depth treated as a continuous variable. Secondary outcomes included compliance with American Heart Association (AHA) CPR targets. Analysis was by two-sided unpaired t-test and Chi-square test, as appropriate.

RESULTS

128 out of 140 providers screened met inclusion/exclusion criteria and all 128 consented. The average CC depth (mean (SEM)) was greater in PUSH HARD compared to TWO INCHES (43 (1) vs. 36 (1) mm, p<0.01) and met AHA targets more often (39% (25/64) vs. 20% (13/64), p=0.02). CC rates trended higher in the PUSH HARD group (93 (4) vs. 82 (4) CC/min, p=0.06). More providers did not achieve full chest recoil with PUSH HARD compared to TWO INCHES (53% (34/64) vs. 75% (48/64), p=0.01).

CONCLUSIONS

Simplified dispatcher assisted pediatric CPR instructions: "Push as hard as you can" was associated with lay bystanders providing deeper and faster CCs on a simulated, 6-year-old pediatric manikin. However, percentage of providers leaning between CC increased. The potential effect of these simplified instructions in younger children remains unanswered.

Sternal wall pressure comparable to leaning during CPR impacts intrathoracic pressure and haemodynamics in anaesthetized children during cardiac catheterization

AIM

Force due to leaning during cardiopulmonary resuscitation (CPR) negatively affects haemodynamics and intrathoracic airway pressures (ITP) in animal models and adults, but has not been studied in children. We sought to characterize the effects of sternal force (SF) comparable to leaning force on haemodynamics and ITP in anaesthetized children.

METHODS

Children (6 months to 8yrs) presenting for routine haemodynamic cardiac catheterization with anaesthesia and mechanical ventilation >6 months after cardiac transplant were studied. Haemodynamics and ITP were measured before and during incremental increases in SF of 10% and 20% body weight.

RESULTS

20 subjects (5.4±1.7yrs of age and 18.3±3.3kg) were studied. Mean right atrial pressure (6.5±2.6 at baseline vs. 7.7±2.6 at 10% SF vs. 8.6±2.7mmHg at 20% SF), mean pulmonary capillary wedge pressure (10.2±2.9 at baseline vs. 11±3.3 at 10% SF vs. 11.8±3.4mmHg at 20% SF) and ITP (16.3±3.2 at baseline vs. 17.9±3.9 at 10% SF vs. 19.5±4cm H2O) all increased significantly with incremental SF (p<0.001 for all). Aortic systolic pressure (85±10mmHg at baseline vs. 83±10mmHg at 10% SF vs. 82±10mmHg at 20% SF, p=0.014) and coronary perfusion pressure (42±7mmHg at baseline vs. 39±7mmHg at 10% SF vs. 38±7mmHg at 20% SF, p<0.001) both decreased significantly with incremental SF.

CONCLUSIONS

In asymptomatic, anaesthetized children after cardiac transplantation, sternal forces comparable to leaning previously reported to occur during CPR elevate ITP and right atrial pressure and decrease coronary perfusion pressure. These haemodynamic effects may be clinically important during CPR and warrant further study.

Forensic analysis of crib mattress properties on pediatric CPR quality--can we balance pressure reduction with CPR effectiveness?

INTRODUCTION

Single mode, pressure reduction (PR) crib mattresses are increasingly employed in hospitals to prevent skin injury and infection. However, single mode PR mattresses risk large mattress deflection during CPR chest compressions, potentially leading to inadequate chest compressions.

HYPOTHESIS

New, dual mode PR crib mattress technology provides less mattress deflection during chest compressions (CCs) with similar PR characteristics for prevention of skin injury.

METHODS

Epochs of 50 high-quality CCs (target sternum-spine compression depth ≥ 38 mm) guided by real-time force/deflection sensor (FDS) feedback were delivered to CPR manikin with realistic CC characteristics on two PR crib mattresses for four conditions: (1) single mode+backboard; (2) dual mode+backboard; (3) single mode-no backboard; and (4) dual mode-no backboard. Mattress displacement was measured using surface reference accelerometers. Mattress displacement ≥ 5 mm was prospectively defined as minimal clinically important difference. PR qualities of both mattresses were assessed by tissue interface pressure mapping.

RESULTS

During simulated high quality CC, single mode had significantly more mattress displacement compared to dual mode (mean difference 16.5 ± 1.4mm, p<0.0001) with backboard. This difference was greater when no backboard was used (mean difference 31.7 ± 1.5mm, p<0.0001). Both single mode and dual mode met PR industry guidelines (mean surface pressure <50 mm Hg).

CONCLUSIONS

Chest compressions delivered on dual mode pressure reduction crib mattresses resulted in substantially smaller mattress deflection compared to single mode pressure reduction mattresses. Skin pressure reduction qualities of dual mode pressure reduction crib mattress were maintained. We recommend that backboards continue to be used in order to mitigate mattress deflection during CPR on soft mattresses.

American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest

AIM

To evaluate the association between cardiopulmonary resuscitation (CPR) quality and hemodynamic measurements during in-hospital pediatric cardiac arrest. We hypothesized that AHA recommended CPR rate and depth targets would be associated with systolic blood pressures≥80mmHg and diastolic blood pressures≥30mmHg.

METHODS

In children and adolescents <18 years of age who suffered a cardiac arrest with an invasive arterial catheter in place, a CPR monitoring defibrillator collected CPR data which was synchronized to arterial blood pressure (BP) tracings. Chest compression (CC) depths were corrected for mattress deflection. Generalized least squares regression estimated the association between BP and CPR quality, treated as continuous variables. Mixed-effects logistic regression estimated the association between systolic BP≥80mmHg/diastolic BP≥30mmHg and the AHA targets of depth≥38mm and/or rate≥100/min.

RESULTS

Nine arrests resulted in 4156 CCs. The median mattress corrected depth was 32mm (IQR 28-38); median rate was 111CC/min (IQR 103-120). AHA depth was achieved in 1090/4156 (26.2%) CCs; rate in 3441 (83.7%). Systolic BP≥80mmHg was attained in 2516/4156 (60.5%) compressions; diastolic≥30mmHg in 2561/4156 (61.6%). A rate≥100/min was associated with systolic BP≥80mmHg (OR 1.32; CI(95) 1.04, 1.66; p=0.02) and diastolic BP≥30mmHg (OR 2.15; CI(95) 1.65, 2.80; p<0.001). Exceeding both (rate≥100/min and depth≥38mm) was associated with systolic BP≥80mmHg (OR 2.02; CI(95) 1.45, 2.82; p<0.001) and diastolic BP≥30mmHg (OR 1.48; CI(95) 1.01, 2.15; p=0.042).

CONCLUSIONS

AHA quality targets (rate≥100/min and depth≥38mm) were associated with systolic BPs≥80mmHg and diastolic BPs≥30mmHg during CPR in children.

Backboards are important when chest compressions are provided on a soft mattress

AIM

Determine the impact of backboard placement, torso weight and bed compression on chest compression (CC) depth feedback in simulated cardiac arrest patients.

METHODS

Epochs of 50 high quality CCs with real-time feedback of sternum-to-spine compression depth were provided by a blinded BLS/ACLS/PALS certified provider on manikins of two torso weights (25 vs. 50 kg), using three bed surfaces (stretcher, Stryker hospital bed with Impression mattress, soft Total Care ICU bed), with/without a backboard (BB). Two BB sizes were tested (small: 60 cm × 50 cm; large: 89 cm × 50 cm) in vertical vs. horizontal orientation. Mattress displacement was measured using an accelerometer placed internally on the spine plate of the manikin. Mattress displacement of ≥ 5 mm was prospectively defined as the minimal clinically important difference.

RESULTS

During CPR (CC depth: 51.8 ± 2.8mm), BB use significantly reduced mattress displacement only for soft ICU beds. Mattress displacement was reduced (vs. no BB) for 25 kg torso weight: small BB12.3mm (95%CI 11.9-12.6), horizontally oriented large BB 11.2mm (95%CI 10.8-11.7), and vertically oriented large BB 12.2mm (95%CI 11.8-12.6), and for 50 kg torso weight: small BB 7.4mm (95%CI 7.1-7.8), horizontally oriented large BB 7.9 mm (95%CI 7.6-8.3), and vertically oriented large BB 6.2mm (95%CI 5.8-6.5; all p<0.001). BB size and orientation did not significantly affect mattress displacement. Lighter torso weight was associated with larger displacement in soft ICU beds without BB (difference: 6.9 mm, p<0.001).

CONCLUSION

BB is important for CPR when performed on soft surfaces, such as ICU beds, especially when torso weight is light. BB may not be needed on stretchers, relatively firm hospital beds, or for patients with heavy torso weights.

Prevalence and hemodynamic effects of leaning during CPR

BACKGROUND

Cardiopulmonary resuscitation (CPR) guidelines recommend complete release between chest compressions (CC).

OBJECTIVE

Evaluate the hemodynamic effects of leaning (incomplete chest wall release) during CPR and the prevalence of leaning during CPR.

RESULTS

In piglet ventricular fibrillation cardiac arrests, 10% and 20% (1.8 kg and 3.6 kg, respectively), leaning during CPR increased right atrial pressures, decreased coronary perfusion pressures, and decreased cardiac index and left ventricular myocardial blood flow by nearly 50%. In contrast, residual leaning of a 260 g accelerometer/force feedback device did not adversely affect cardiac index or myocardial blood flow. Among 108 adult in-hospital CPR events, leaning ≥ 2.5 kg was demonstrable in 91% of the events and 12% of the evaluated CC. For 12 children with in-hospital CPR, 28% of CC had residual leaning ≥ 2.5 kg and 89% had residual leaning ≥ 0.5 kg.

CONCLUSIONS

Leaning during CPR increases intrathoracic pressure, decreases coronary perfusion pressure, and decreases cardiac output and myocardial blood flow. Leaning is common during CPR.

Training hospital providers in basic CPR skills in Botswana: acquisition, retention and impact of novel training techniques

OBJECTIVE

Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana.

METHODS

HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation.

RESULTS

Of 214 HCP trained, 40% resuscitate ≥ 1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p<0.01; adult 28% vs. 48%, p<0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p<0.01) and 6 months (38% vs. 67%, p<0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p=0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance.

CONCLUSIONS

HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction.

Comparison of relative and actual chest compression depths during cardiac arrest in children, adolescents, and young adults

AIM

Cardiopulmonary resuscitation (CPR) guidelines recommend specific chest compression (CC) target depths for children. We quantitatively describe relative anterior-posterior diameter (APD) depth, actual depth, and force of CCs during real CPR events in children.

METHODS

CC depth and force were recorded during real CPR events in children ≥8 years using FDA-approved CC sensor. Patient chest APD was measured at conclusion of each CPR event. CC data was stratified and analyzed according to age (pre-puberty, 8-14 years; post-puberty, 15+ years). Relative (% APD) and actual CC depth, corrected for mattress deflection, were assessed and compared with American Heart Association (AHA) 2005 and 2010 pediatric CPR guidelines.

RESULTS

35 events in 32 subjects included 16,158 CCs for data analysis: 16 pre-puberty (CCs=7484, age 11.9±2 years, APD 164.6±25.1 mm); 19 post-puberty (CCs=8674, age 18.0±2.7 years, APD 196.5±30.4 mm). After correction for mattress deflection, 92% of CC delivered to pre-puberty were <1/3 relative APD and 60% of CC were <38 mm actual depth. Mean actual CC depth (36.2±9.6 mm vs. 36.8±9.9 mm, p=0.64), mean relative APD (22.5%±7.0% vs. 19.5±6.7%, p=0.13), and mean CC force (30.7±7.6 kg vs. 33.6±9.4 kg, p=0.07) were not significantly less in pre-puberty vs. post-puberty.

CONCLUSIONS

During in-hospital cardiac arrest of children ≥8 years, CCs delivered by resuscitation teams were frequently <1/3 relative APD and <38 mm actual depth after mattress deflection correction, below pediatric and adult target guidelines. Mean CC actual depth and force were not significantly different in pre-puberty and post-puberty. Additional investigation to determine depth of CCs to optimize hemodynamics and outcomes is needed to inform future CPR guidelines.

Does change in thoracic impedance measured via defibrillator electrode pads accurately detect ventilation breaths in children?

INTRODUCTION

Resuscitation guidelines recommend rescue ventilations consist of tidal volumes 7-10 ml/kg. Changes in thoracic impedance (ΔTI) measured using defibrillator electrode pads to detect and guide rescue ventilations have not been studied in children.

AIM

We hypothesized that ΔTI measured via standard anterior-apical (AA) position can accurately detect ventilations with volume > 7 ml/kg in children. We also compared standard AA position with alternative anterior-posterior (AP) position.

METHODS

IRB-approved, prospective, observational study of sedated, subjects (6 months to 17 years) on conventional mechanical ventilation. Thoracic impedance (TI) was obtained via Philips MRx defibrillator with standard electrode pads for 5 min each in AA and AP positions. Ventilations were simultaneously measured by pneumotachometer (Novametrix CO(2)SMO Plus).

RESULTS

Twenty-eight subjects (median 4 years, IQR 1.7-9 years; median 16.3 kg, IQR 10.5-39 kg) were enrolled. Data were available for 21 episodes in AA position and 22 episodes in AP position, with paired AA and AP data available for 18. For ventilations with volume < 7 ml/kg, the defibrillator algorithm detected 80.0% for both AA and AP (p=0.99). For ventilations ≥ 7 ml/kg, detection was 95.1% for AA and 95.7% for AP (p=0.38).

CONCLUSIONS

Changes in thoracic impedance obtained via defibrillator pads can accurately detect ventilations above 7 ml/kg in stable, mechanically ventilated children, corresponding to rescue ventilations recommended during CPR. Both AA and AP pad positions were less sensitive to detect smaller volumes (< 7 ml/kg) than higher volumes (≥ 7 ml/kg), suggesting that shallow ventilations during CPR might be missed. There were no differences in impedance measurements between standard AA pad position and commonly used alternative AP pad position.

Analysis of transthoracic impedance during real cardiac arrest defibrillation attempts in older children and adolescents: are stacked-shocks appropriate?

BACKGROUND

In 2005, the AHA changed the treatment recommendation for shockable rhythms from 3 transthoracic stacked-shocks to a single shock followed by immediate chest compressions. The stacked-shock recommendation was based on low first-shock efficacy of monophasic waveforms and the theoretical decrease in transthoracic impedance (TTI) following each shock. The objective of this study was to characterize TTI following biphasic defibrillation attempts in children ≥ 8 yrs during cardiac arrest to assess whether a stacked-shock approach may be appropriate to improve defibrillation success.

METHODS

TTI (Ohms (Ω)) was collected via standard anterior-apical defibrillator electrode pads during consecutive in-hospital cardiac arrest biphasic defibrillation attempts in children ≥ 8 yrs. Analytic data points for TTI were: 0.1s pre-shock (baseline); post-shock at 0.1, 0.5, 1.0, 1.5, and 2.0 s. TTI variables analyzed with descriptive summaries/paired t-test. p values < 0.05 considered statistically significant after correction for multiple comparisons.

RESULTS

Analysis yielded 13 evaluable shock events during 5 cardiac arrests (mean age 14.3 ± 5 yrs, weight 47.4 ± 7.3 kg) between September 2006 and May 2009. Compared to 0.1s pre-shock baseline values (56.8 ± 23.4 Ω), TTI was significantly lower immediately 0.1s post-shock (55.2 ± 22.2 Ω, p = 0.003). Post-shock mean difference from baseline was 1.6 Ω at 0.1s (p = 0.015), 1.4 Ω at 0.5s (p = 0.019) 1.4 Ω at 1.0 s (p = 0.023), 1.1 Ω at 1.5 s (p = 0.028), and 0.95 Ω at 2.0 s (p = 0.096). Time to recharge our clinical defibrillators to standard biphasic shock dose was 2.80 ± 0.05 s.

CONCLUSIONS

During cardiac arrests in children ≥ 8 yrs, TTI decreased after biphasic shocks, but the limited magnitude and duration of TTI changes suggest that stacked-shocks would not improve defibrillation success.