Pediatric In-Hospital Cardiopulmonary Resuscitation Research Articles

Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study

BackgroundHalf of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness.MethodsPrespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016–March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status.ResultsOf 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001).ConclusionsIn this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.

The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

BackgroundEpinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.MethodsThis was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as “responders.”ResultsAmong 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [− 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: − 1.5 [− 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1–3 or no worsening from baseline).ConclusionsThe change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.

Effect of life-sustaining treatment decision law on pediatric in-hospital cardiopulmonary resuscitation rate: A Korean population-based study

AimThe 2018 life-sustaining treatment (LST) decision law is expected to improve end-of-life quality in Korea. This study evaluated the national effect of the LST decision law on the cardiopulmonary resuscitation (CPR) rate among pediatric patients who died during hospital admission. MethodsThis retrospective cohort study was based on the Korean National Health Insurance database. Pediatric admissions within 12 months before or after implementation of the LST decision law were compared, allowing a 1-month transition period (February 2018). The changes in mortality, CPR, and documentation of LST decision were evaluated. ResultsThe CPR rate of patients who died in hospital decreased after establishment of the LST decision law (49.6 vs 43.4 %, P = 0.04), without change of in-hospital mortality between pre/post-LST decision law activation (0.83 vs 0.81 per 1000 admissions, P = 0.67). In addition, in-hospital CPR (0.73 vs 0.67 per 1000 admissions, P = 0.15) and survival to discharge after in-hospital CPR (43.6 vs 47.2 %, P = 0.27) were slightly improved, although there was no statistical significance. Patients with LST decision documentation were less frequently mechanically ventilated (69.8 % vs 80.4 %, P < 0.01) and used fewer inotropes (76.5 % vs 90.1 %, P < 0.01) and more frequent opioids (67.1 % vs 57.4 %, P = 0.04). ConclusionsThe legally guided process of LST decision can decrease the CPR rate of children who die in hospitals. This result highlights the possibility of improving end-of-life quality by reducing non-beneficial in-hospital CPR.

Hemodynamic effects of chest compression interruptions during pediatric in-hospital cardiopulmonary resuscitation

AimAnimal studies have established deleterious hemodynamic effects of interrupting chest compressions. The objective of this study was to evaluate the effect of interruptions on invasively measured blood pressures (BPs) during pediatric in-hospital cardiac arrest (IHCA). MethodsThis was a single-center, observational study of pediatric (<18 years) intensive care unit IHCAs in patients with invasive arterial catheters in place. Interruptions were defined as ≥1 s between chest compressions. Diastolic BP (DBP) and systolic BP (SBP) were determined for individual compressions. For the primary analysis, the average DBP and SBP of the 20 compressions preceding each interruption were compared to the average DBP and SBP of the first 20 compressions following each interruption utilizing non-parametric paired analyses. Linear regression evaluated the change in DBP during interruptions and following interruptions. ResultsThirty-two IHCA events met inclusion criteria, yielding 161 evaluable interruptions. The median age was 2.1 years. Return of circulation was achieved in 24 (75%). The median interruption duration was 2.4 [1.4, 7.0] seconds. Most patients were intubated pre-arrest and received epinephrine during CPR. BPs were not different pre- vs. post-interruption (DBP: 28.7 [21.6, 38.2] vs. 28.3 [21.0, 37.4] mmHg, p = 0.81; SBP: 82.0 [51.7, 116.7] vs. 85.4 [55.7, 122.2] mmHg, p = 0.07). DBP decreased 8.41 ± 0.73 mmHg (p < 0.001) during the first second of interruptions and 0.19 ± 0.02 mmHg/s (p < 0.001) in subsequent seconds. ConclusionsBPs following chest compression interruptions did not differ from pre-interruption BPs. These findings suggest that in the setting of high-quality in-hospital CPR, brief chest compression interruptions do not have persistent detrimental hemodynamic impact.

Abstract 160: End-Tidal Carbon Dioxide &gt; 20mmHg During Pediatric In-Hospital Cardiopulmonary Resuscitation is not Associated With Survival

Introduction: Based on laboratory CPR investigations and limited adult data, the American Heart Association Consensus Statement on CPR Quality recommends titrating end-tidal carbon dioxide (ETCO2) to &amp;gt; 20 mmHg during CPR. Hypothesis: ETCO2 &amp;gt; 20 mmHg during pediatric in-hospital CPR is associated with survival to hospital discharge. Methods: Children &amp;gt; 37 weeks gestation in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for &amp;gt; 1 minute and ETCO2 monitoring prior to and during CPR between July 1, 2013 and June 31, 2016 were included. ETCO2 and Utstein-style cardiac arrest data were collected. Multivariable Poisson regression models with robust error estimates were used to estimate relative risk of outcomes. Results: Investigators blinded to outcome analyzed ETCO2 waveforms from 43 children for the first (up to) 10 minutes of CPR. During CPR, the median ETCO2 was 23 mmHg (quartiles, 16 and 28 mmHg), median ventilation rate was 29 breaths/minute (quartiles, 24 and 35 bpm), and median duration of CPR was 5 minutes [quartiles, 2 and 16 minutes]. Return of spontaneous circulation occurred after 71% of CPR events and 37% of patients survived to hospital discharge. For children with mean ETCO2 during CPR &amp;gt; 20 mmHg, the adjusted relative risk for return of spontaneous circulation was 1.32 (0.89, 1.95), p= 0.16 and for survival to hospital discharge was 0.92 (0.41, 2.08), p= 0.84. Further sensitivity analyses were unable to demonstrate an association between mean ETCO2 &amp;gt; 25 mmHg or &amp;gt; 30 mmHg and ROSC or survival to hospital discharge. The median mean ETCO2 among children who survived to hospital discharge was 20 mmHg [quartiles; 15, 28 mmHg] versus 23 mmHg [16, 28 mmHg] among non-survivors. Conclusion: Mean ETCO2 &amp;gt; 20 mmHg during pediatric in-hospital CPR was not associated with ROSC or survival to hospital discharge. ETCO2 was not demonstrably different among survivors versus non-survivors.

End-tidal carbon dioxide during pediatric in-hospital cardiopulmonary resuscitation

BackgroundBased on laboratory cardiopulmonary resuscitation (CPR) investigations and limited adult data, the American Heart Association Consensus Statement on CPR Quality recommends titrating CPR performance to achieve end-tidal carbon dioxide (ETCO2) >20 mmHg. AimsWe prospectively evaluated whether ETCO2 > 20 mmHg during CPR was associated with survival to hospital discharge. MethodsChildren ≥37 weeks gestation in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for ≥1 min and ETCO2 monitoring prior to and during CPR between July 1, 2013 and June 31, 2016 were included. ETCO2 and Utstein-style cardiac arrest data were collected. Multivariable Poisson regression models with robust error estimates were used to estimate relative risk of outcomes. ResultsBlinded investigators analyzed ETCO2 waveforms from 43 children. During CPR, the median ETCO2 was 23 mmHg [quartiles, 16 and 28 mmHg], median ventilation rate was 29 breaths/min [quartiles, 24 and 35 breaths/min], and median duration of CPR was 5 min [quartiles, 2 and 16 min]. Return of spontaneous circulation occurred after 71% of CPR events and 37% of patients survived to hospital discharge. For children with mean ETCO2 during CPR > 20 mmHg, the adjusted relative risk for survival was 0.92 (0.41, 2.08), p = 0.84. The median mean ETCO2 among children who survived to hospital discharge was 20 mmHg [quartiles; 15, 28 mmHg] versus 23 mmHg [16, 28 mmHg] among non-survivors. ConclusionMean ETCO2 > 20 mmHg during pediatric in-hospital CPR was not associated with survival to hospital discharge, and ETCO2 was not different in survivors versus non-survivors.

Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes

AimThe primary aim of this study was to evaluate the association between chest compression rates and 1) arterial blood pressure and 2) survival outcomes during pediatric in-hospital cardiopulmonary resuscitation (CPR). MethodsProspective observational study of children ≥37 weeks gestation and <19 years old who received CPR in an intensive care unit (ICU) as part of the Pediatric Intensive Care Unit Quality of CPR Study (PICqCPR) of the Collaborative Pediatric Critical Care Research Network (CPCCRN). Arterial blood pressure and compression rate were determined from manually extracted arterial line waveform data during the first 10 min of CPR. The primary outcome was survival to hospital discharge. Modified Poisson regression models assessed the association between rate categories (80–<100, 100–120 [Guidelines], >120–140, >140) and outcomes. ResultsCompression rate data were available for 164 patients. More than half (98/164; 60%) were <1 year old. Return of circulation was achieved in 148/164 (90%); survival to hospital discharge in 77/164 (47%). Percentage of events with average rate within Guidelines was 32.9%. Compared to Guidelines, higher rate categories were associated with lower systolic blood pressures (>120–140, p = 0.010; >140, p = 0.077), but not survival. A rate between 80-<100 per minute was associated with a higher rate of survival to hospital discharge (aRR 1.92, CI95 1.13, 3.29, p = 0.017) and survival with favorable neurological outcome (aRR 2.12, CI95 1.09, 4.13, p = 0.027) compared to Guidelines. ConclusionNon-compliance with compression rate Guidelines was common in this multicenter cohort. Among ICU patients, slightly lower rates were associated with improved outcomes compared to Guidelines.

Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative.

Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals. Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017. Twelve pediatric hospitals across United States, Canada, and Europe. In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings. None. There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3 cm (1.9-3.0 cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8 cm (2.9-4.6 cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5 cm (4.0-6.5 cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4 cm in less than 1 year, greater than or equal to 4.4 cm in 1 to less than 8 years, and 4.5 to less than 6.6 cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112). Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival.

On the basis of laboratory cardiopulmonary resuscitation (CPR) investigations and limited adult data demonstrating that survival depends on attaining adequate arterial diastolic blood pressure (DBP) during CPR, the American Heart Association recommends using blood pressure to guide pediatric CPR. However, evidence-based blood pressure targets during pediatric CPR remain an important knowledge gap for CPR guidelines. All children ≥37 weeks' gestation and <19 years old in Collaborative Pediatric Critical Care Research Network intensive care units with chest compressions for ≥1 minute and invasive arterial blood pressure monitoring before and during CPR between July 1, 2013, and June 31, 2016, were included. Mean DBP during CPR and Utstein-style standardized cardiac arrest data were collected. The hypothesis was that DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old would be associated with survival. Primary outcome was survival to hospital discharge. Secondary outcome was survival to hospital discharge with favorable neurological outcome, defined as Pediatric Cerebral Performance Categories 1 to 3 or no worse than prearrest baseline. Multivariable Poisson regression models with robust error estimates were used to estimate the relative risk of outcomes. Blinded investigators analyzed blood pressure waveforms during CPR from 164 children, including 60% <1 year old, 60% with congenital heart disease, and 54% after cardiac surgery. The immediate cause of arrest was hypotension in 67%, respiratory decompensation in 44%, and arrhythmia in 19%. Median duration of CPR was 8 minutes (quartiles, 3 and 27 minutes). Ninety percent survived the event, 68% with return of spontaneous circulation and 22% by extracorporeal life support. Forty-seven percent survived to hospital discharge, and 43% survived to discharge with favorable neurological outcome. Maintaining mean DBP ≥25 mm Hg in infants and ≥30 mm Hg in children ≥1 year old occurred in 101 of 164 children (62%) and was associated with survival (adjusted relative risk, 1.7; 95% confidence interval, 1.2-2.6; P=0.007) and survival with favorable neurological outcome (adjusted relative risk, 1.6; 95% confidence interval, 1.1-2.5; P=0.02). These data demonstrate that mean DBP ≥25 mm Hg during CPR in infants and ≥30 mm Hg in children ≥1 year old was associated with greater likelihood of survival to hospital discharge and survival with favorable neurological outcome.

Univariate analysis of pediatric in-hospital cardiopulmonary resuscitation

Objective To study the influencing factors of pediatric in-hospital cardiopulmonary resuscitation(CPR). Methods It was a retrospective observational study.We studied a total of 281 children who suffered in-hospital cardiopulmonary arrest(CPA). The outcome was defined as sustained return of spontaneous circulation>20 min. Results A total of 281 patients met study entry criteria.In 129 children(45.9%), return of spontaneous circulation sustained >20 min and 20 cases(8.8%) survived to hospital discharge.In the univariate analysis, gender, age, weight, time of CPA happened, first cardiac rhythm, pH, blood lactate had no obvious influence on the outcome.Underlying disease, the place of CPA, personnel factors, airway support, the duration of CPR, doses of adrenaline, use of bicarbonate and blood glucose level were associated with outcome. Conclusion At present, the rate of successful CPR and discharge of hospital is still low.Respiratory disease has a higher survival rate.CPR>20 min, use of bicarbonate and using adrenaline≥3 doses are associated with poor outcome and an increase in mortality. Key words: Cardiopulmonary resuscitation; Cardiopulmonary arrest; Children

The Success Rate of Pediatric In-Hospital Cardiopulmonary Resuscitation in Ahvaz Training Hospitals.

Research Objective. This study determined the outcome of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest and factors influencing it in two training hospitals in Ahvaz. Method. Patients hospitalized in the pediatric wards and exposed to CPR during hospital stay were included in the study (September 2013 to May 2014). The primary outcome of CPR was assumed to be the return of spontaneous circulation (ROSC) and the secondary outcome was assumed to be survival to discharge. The neurological outcome of survivors was assessed using the Pediatric Cerebral Performance Category (PCPC) method. Results. Of the 279 study participants, 138 patients (49.4%) showed ROSC, 81 patients (29%) survived for 24 hours after the CPR, and 33 patients (11.8%) survived to discharge. Of the surviving patients, 16 (48.5%) had favorable neurological outcome. The resuscitation during holidays resulted in fewer ROSC. Multivariate analysis showed that longer CPR duration, CPR by junior residents, growth deficiency, and prearrest vasoactive drug infusion were associated with decreased survival to discharge (p < 0.05). Infants and patients with respiratory disease had higher survival rates. Conclusion. The rate of successful CPR in our study was lower than rates reported by developed countries. However, factors influencing the outcome of CPR were similar. These results reflect the necessity of paying more attention to pediatric CPR training, postresuscitation conditions, and expansion of intensive care facilities.

Epidemiology and outcome of pediatric in-hospital cardiopulmonary resuscitation in Northern India.

Data regarding in-hospital pediatric cardiopulmonary resuscitation (CPR) are limited because of retrospective study designs and inconsistent definitions. There are no Indian studies on pediatric CPR. Accordingly, we conducted this retrospective study to determine the outcome of in-hospital CPR and assess which variables predict outcome. Consecutive in-hospital CPR events in children aged 1-mo to 14-yr during a 1 yr period were described prospectively using Utstein guidelines. Variables affecting outcome were evaluated by univariate and multivariate analysis. A total of 427 patients were enrolled and received CPR. The indication for CPR was primary respiratory failure in 213 (50%) and clinical cardiac arrest in 191 (44%). The most common underlying etiology was neurological illness (26%). Sustained return of spontaneous circulation was attained in 112 (26%). Fifty-three (12%) patients were alive at 24 h, of which only 8 (1.87%) were alive at discharge. Of those patients who survived to discharge, all were alive after 6 mo. Multivariate logistic regression analysis showed that CPR during night hours (adjusted odds ratio [aOR]: 3.73), CPR of more than 10 min duration (aOR: 27.04) and cardiac arrest as an indication of CPR (aOR: 2.56) were independently associated with poor immediate outcome. Factors associated with death within 24 h were CPR during night hours (aOR: 3.17), age > 1 yr (aOR: 5.52) and cardiac arrest (aOR: 4.93). Good neurological outcome was found in seven out of eight (87.5%) patients at follow up. We conclude that pediatric cardiac arrest in a tertiary hospital in India has a poor outcome even after survival beyond 24 h; however, neurological outcome is generally good among survivors.

Ratio of PICU Versus Ward Cardiopulmonary Resuscitation Events Is Increasing*

The aim of this study was to evaluate the relative frequency of pediatric in-hospital cardiopulmonary resuscitation events occurring in ICUs compared to general wards. We hypothesized that the proportion of pediatric cardiopulmonary resuscitation provided in ICUs versus general wards has increased over the past decade, and this shift is associated with improved resuscitation outcomes. Prospective and observational study. Total of 315 hospitals in the American Heart Association's Get With The Guidelines-Resuscitation database. Total of 5,870 pediatric cardiopulmonary resuscitation events between January 1, 2000 and September 14, 2010. Cardiopulmonary resuscitation events were defined as external chest compressions longer than 1 minute. None. The primary outcome was proportion of total ICU versus general ward cardiopulmonary resuscitation events over time evaluated by chi-square test for trend. Secondary outcome included return of spontaneous circulation following the cardiopulmonary resuscitation event. Among 5,870 pediatric cardiopulmonary resuscitation events, 5,477 (93.3%) occurred in ICUs compared to 393 (6.7%) in inpatient wards. Over time, significantly more of these cardiopulmonary resuscitation events occurred in the ICU compared to the wards (test for trend: p<0.01), with a prominent shift noted between 2003 and 2004 (2000-2003: 87-91% vs 2004-2010: 94-96%). In a multivariable model controlling for within center variability and other potential confounders, return of spontaneous circulation increased in 2004-2010 compared with 2000-2003 (relative risk, 1.08; 95% CI, 1.03-1.13). In-hospital pediatric cardiopulmonary resuscitation is much more commonly provided in ICUs than in wards, and the proportion has increased significantly over the past decade, with concomitant increases in return of spontaneous circulation.

Abstract 321: Sodium Bicarbonate Use During In-hospital Pediatric Cardiopulmonary Resuscitation - A Report From the American Heart Association Get With The Guidelines-Resuscitation®

OBJECTIVES: The 2005 and 2010 Pediatric Advanced Life Support (PALS) Guidelines do not recommend using sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR) except for select resuscitation situations. We hypothesize that SB is used frequently during in-hospital pediatric CPR and its use is associated with worse survival to hospital discharge when given outside of these recommended resuscitation situations. PATIENTS AND METHODS: We analyzed data from 8602 consecutive pediatric CPR events (patients &lt; 18 yrs) submitted to the American Heart Association Get With The Guidelines-Resuscitation from January 2000 through September 2010. The primary outcome was survival to hospital discharge. Secondary outcomes included event survival, 24 hr survival, and neurologic outcome. Multivariable logistic regression was performed to analyze the association between SB use and outcomes. RESULTS: SB was used in 3923 (46%) of 8602 events. The incidence of SB use between 2000-2005 vs. 2006-2010 was 54% vs. 41% (p &lt;0.001; Fig. 1). After adjustment for confounding factors (e.g. event location, illness category, arrest rhythm, concurrent advanced cardiac life support medications, and duration of CPR &gt; 15 mins), the use of SB during CPR was associated with decreased survival to discharge (OR: 0.62; 95% CI: 0.54, 0.71), but not unfavorable neurologic outcome (OR 0.73; 95% CI 0.50, 1.05). In the settings of metabolic/electrolyte abnormalities, toxicologic abnormalities/overdose /poisoning, and high potassium, SB use during CPR was not associated with worse survival to discharge (OR: 0.78; 95% CI: 0.56; 1.09) or unfavorable neurologic outcome (OR 1.05; 95% CI: 0.37, 2.97). After excluding patients in the settings of metabolic/electrolyte abnormalities, toxicologic abnormalities, and hyperkalemia, SB use during CPR (n = 5270) continued to be associated with worse survival to discharge (OR: 0.61; 95% CI: 0.53, 0.71) and unfavorable neurologic outcome (OR: 0.64; 95% CI: 0.43, 0.95). CONCLUSIONS: Sodium bicarbonate continues to be used frequently during in-hospital pediatric CPR, yet there is a significant trend towards less routine use over the last decade. Sodium bicarbonate use is associated with decreased survival to hospital discharge and unfavorable neurologic outcome when given outside PALS recommendations.

PC-FACS

PC-FACS

Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States

Population-based data on pediatric in-hospital cardiopulmonary resuscitation in the United States are scarce. Single-center studies and voluntary registries may skew the estimated prevalence and outcomes. This study aimed to determine the prevalence and outcomes of pediatric cardiopulmonary resuscitation on a national scale. A retrospective analysis of the Healthcare Cost and Utilization Project 2006 Kids' Inpatient Database was performed. Sample weighting was employed to produce national estimates. Three thousand seven hundred thirty-nine hospitals in 38 states participating with the Kids' Inpatient Database. All patients <20 yrs of age hospitalized in participating institutions in 2006. Cardiopulmonary resuscitation was performed in 5,807 (95% confidence interval 5259-6355) children with prevalence of 0.77 per 1,000 admissions. Most patients (68%) were <1 yr old, and 44% were female. On multivariable analysis, cardiopulmonary resuscitation was associated with respiratory failure (odds ratio 41.5, 95% confidence interval 35.4-48.8), myocarditis (odds ratio 36.6, 95% confidence interval 21.9-61.0), acute renal failure (odds ratio 21.6, 95% confidence interval 17.5-26.7), heart failure (odds ratio 3.8, 95% confidence interval 3.0-4.8), and cardiomyopathy (odds ratio 3.8, 95% confidence interval 3.2-4.7). Overall mortality was 51.8% and greater among patients ≥1 yr (68%) vs. <1 yr (44%) (odds ratio 2.7, 95% confidence interval 2.3-3.2). Factors associated with mortality among patients receiving cardiopulmonary resuscitation on multivariable analysis included acute renal failure (odds ratio 1.5, 95% confidence interval 1.1-1.9), hepatic insufficiency (odds ratio 1.5, 95% confidence interval 1.01-2.4), sepsis (odds ratio 1.2, 95% confidence interval 1.01-1.4), and congenital heart disease (odds ratio 1.2, 95% confidence interval 1.01-1.5). Cardiopulmonary resuscitation is performed in approximately one in 1,300 pediatric hospitalizations. Approximately half of patients receiving cardiopulmonary resuscitation do not survive to discharge. Independent risk factors for mortality after receiving cardiopulmonary resuscitation included congenital heart disease, age ≥1 yr, acute renal failure, hepatic insufficiency, and sepsis.

Childhood Obesity and Survival After In-Hospital Pediatric Cardiopulmonary Resuscitation

We hypothesized that childhood obesity would be associated with decreased likelihood of survival to hospital discharge after in-hospital, pediatric cardiopulmonary resuscitation (CPR). We reviewed 1477 consecutive, pediatric, CPR index events (defined as the first CPR event during a hospitalization in that facility for a patient <18 years of age) reported to the American Heart Association National Registry of Cardiopulmonary Resuscitation between January 2000 and July 2004. The primary outcome was survival to hospital discharge. A total of 1268 index subjects (86%) with complete registry data were included for analysis. Children were classified as obese (> or =95th weight-for-length percentile if <2 years of age or > or =95th BMI-for-age percentile if > or =2 years of age) or underweight (<5th weight-for-length percentile if <2 years of age or <5th BMI-for-age percentile if > or =2 years of age), with adjustment for gender. Obesity was noted for 213 (17%) of 1268 subjects and underweight for 571 (45%) of 1268 subjects. Obesity was more likely to be associated with male gender, noncardiac medical illness, and cancer and inversely associated with heart failure. Underweight was more likely to be associated with male gender, cardiac surgery, and prematurity and inversely associated with age and cancer. Self-reported, process-of-care, CPR quality was generally worse for obese children. With adjustment for important potential confounding factors, obesity was independently associated with worse odds of event survival (adjusted odds ratio: 0.58 [95% confidence interval: 0.35-0.76]) and survival to hospital discharge (adjusted odds ratio: 0.62 [95% confidence interval: 0.38-0.93]) after in-hospital, pediatric CPR. Underweight was not associated with worse outcomes. Childhood obesity is associated with a lower rate of survival to hospital discharge after in-hospital, pediatric CPR.

Quantitative Analysis of CPR Quality During In-Hospital Resuscitation of Older Children and Adolescents

Few data exist on pediatric cardiopulmonary resuscitation (CPR) quality. This study is the first to evaluate actual in-hospital pediatric CPR. We hypothesized that with bedside CPR training and corrective feedback, CPR quality can approach American Heart Association (AHA) targets. Using CPR recording/feedback defibrillators, quality of CPR was assessed for patients >or=8 years of age who suffered a cardiac arrest in the PICU or emergency department (ED). Before and during the study, a bedside CPR training program was initiated. Between October 2006 and February 2008, twenty events in 18 patients met inclusion criteria and resulted in 36749 evaluable chest compressions (CCs) during 392.3 minutes of arrest. CCs were shallow (<38 mm or <1.5 in) in 27.2% (9998 of 36749), with excessive residual leaning force (>or=2500 g) in 23.4% (8611 of 36749). Segmental analysis of the first 5 minutes of the events demonstrated that shallow CCs and excessive residual leaning force were less prevalent during the first 5 minutes. AHA targets were not achieved for CC rate in 62 (43.1%) of 144 segments, CC depth in 52 (36.1%) of 144 segments, and residual leaning force in 53 (36.8%) of 144 segments. This prospective, observational study demonstrates feasibility of monitoring in-hospital pediatric CPR. Even with bedside CPR retraining and corrective audiovisual feedback, CPR quality frequently did not meet AHA targets. Importantly, no flow fraction target of 10% was achieved. Future studies should investigate novel educational methods and targeted feedback technologies.

Calcium Use During In-hospital Pediatric Cardiopulmonary Resuscitation: A Report From the National Registry of Cardiopulmonary Resuscitation

Specific patterns of calcium use during in-hospital pediatric cardiopulmonary resuscitation have not been reported since publication of pediatric advanced life support guidelines by the American Heart Association in 2000 recommended that calcium use during cardiopulmonary resuscitation be limited to select circumstances. We hypothesized that calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation and that its use is associated with worse survival to hospital discharge. We reviewed 1477 consecutive pediatric cardiopulmonary resuscitation index events (for patients younger than 18 years) submitted to the National Registry of Cardiopulmonary Resuscitation from January 2000 through July 2004. The primary outcome was survival to hospital discharge. Secondary outcomes included survival of event and neurologic outcome. Multivariable logistic regression was performed to analyze the association between calcium use and outcomes. Calcium was used in 659 (45%) of 1477 events. Calcium was more likely to be used during cardiopulmonary resuscitation in the settings of pediatric facilities, ICUs, cardiac surgery, cardiopulmonary resuscitation duration of > or = 15 minutes, asystole, and concurrently with other advanced life support medications: epinephrine, vasopressin, sodium bicarbonate, and magnesium sulfate. The use of calcium during cardiopulmonary resuscitation adjusted for confounding factors was associated with decreased survival to discharge and was not associated with favorable neurologic outcome. Calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation. Although epidemiologic associations do not necessarily indicate causality, calcium use during cardiopulmonary resuscitation is associated with decreased survival to hospital discharge and unfavorable neurologic outcome.

In-hospital Pediatric Cardiopulmonary Resuscitation According to Pediatric Utstein Template

Background: The characteristic of pediatric cardiopulmonary resuscitation (CPR) is different from that of adult CPR. It is known that respiratory arrest is more common in pediatric CPR compared to adults. The objective of this study was to report the characteristics of in-hospital CPR according to four pediatric Utstein groups. Methods: We reviewed all medical records that were coded as CPR, care for arrest, defibrillation/cardioversion, and ambu in our children's hospital. We classified the patients in 4 groups, isolated respiratory compromise, pure respiratory arrest, respiratory arrest leading to cardiac arrest and cardiac arrest. The data were summarized and analyzed in pediatric Utstein style. Results: In 2001, 138 patients aged less than 15 years were resuscitated in our children's hospital. The success rate after resuscitation was 100% in the isolated respiratory compromise group, and 100% in the pure respiratory arrest, 54% in the respiratory arrest leading to the cardiac arrest group, and 24.8% in the cardiac arrest group. Conclusions: We conclude that the isolated respiratory compromise group and the pure respiratory arrest have better results than the respiratory arrest leading to the cardiac arrest group and the cardiac arrest group, considering all characteristics.