Invited Commentary

Abstract

In recent years, much attention has been devoted to resuscitation techniques in adults and children in hopes of improving what have historically been dismal outcomes. Meert and colleagues [1Meert K.L. Delius R. Slomine B.S. et al.One-year survival and neurologic outcomes after pediatric open-chest cardiopulmonary resuscitation.Ann Thor Surg. 2019; 107: 1441-1447Abstract Full Text Full Text PDF Scopus (4) Google Scholar] report encouraging results in neurologic outcomes of children after open-chest resuscitation, the vast majority of whom were infants who had undergone cardiac operations, and most of whom were also supported by extracorporeal membrane oxygenation (ECMO). Their thoughtful analysis of data obtained through the Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital trial demonstrated that about half of the children had 1-year survival with good neurologic outcomes. Although the researchers’ hands were somewhat tied by limitations of data collection defined by the original study design, it is equally strengthened by the entry requirement to be comatose, thus including the highest-risk patients. Most would agree that the outcomes are good, perhaps even better than expected given such an aggressive approach in this high-risk population. The authors’ discussion focuses on predictors of outcome to help guide clinicians and parents in management decisions; however, I believe that there is a larger, perhaps hidden, takeaway message. In the mid-1990s the Extracorporeal Life Support Organization examined its database to determine the survival rate of neonates supported on ECMO after the Norwood procedure. It was zero—not a single reported survivor. Some centers concluded that this specific population were therefore not ECMO candidates, but others realized that we needed to change our approach. An improved understanding of shunt management led to improved outcomes, with current post-Norwood ECMO survival rates of 17% to 54% [2Tabbutt S. Ghanayem N. Ravishankar C. et al.Risk factors for hospital morbidity and mortality after the Norwood procedure: a report from the Pediatric Heart Network Single Ventricle Reconstruction trial.J Thorac Cardiovasc Surg. 2012; 144: 882-895Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar], including 25% survival beyond Fontan completion [3Friedland-Little J.M. Aiyagari R. Yu S. Donohue J.E. Hirsch-Romano J.C. Survival through staged palliation: fate of infants supported by extracorporeal membrane oxygenation after the Norwood operation.Ann Thorac Surg. 2014; 97: 659-665Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]—a notable improvement over zero. A similar response is warranted with the current report. Rather than settle for the documented outcomes, we must carefully examine our management strategies, including techniques of sternotomy during cardiopulmonary resuscitation, timing of ECMO utilization, appropriate ECMO flow rates, use of vasoconstrictors, and temperature management, among other factors. We are guided by experience, intuition, and inherent biases, but we lack the support of data. Well-designed studies will provide the information needed for management evolution and continually improved results. Finally, we should congratulate the authors of this and the original trial, which like most quality clinical research, provides us with as many new questions and challenges as conclusions. One-Year Survival and Neurologic Outcomes After Pediatric Open-Chest Cardiopulmonary ResuscitationThe Annals of Thoracic SurgeryVol. 107Issue 5PreviewLimited data exist about neurobehavioral outcomes of children treated with open-chest cardiopulmonary resuscitation (CPR). Our objective was to describe neurobehavioral outcomes 1 year after arrest among children who received open-chest CPR during in-hospital cardiac arrest and to explore factors associated with 1-year survival and survival with good neurobehavioral outcome. Full-Text PDF