National Registry Of Cardiopulmonary Resuscitation Research Articles

Using simulation with interprofessional team training to improve RRT/code performance

Abstract Early recognition of and response to changes in patients' conditions are a National Patient Safety Goal. Rapid Response Teams (RRTs) are one safety strategy aimed at early recognition of signs and symptoms of clinical deterioration and reduction in rates of cardiopulmonary arrest and death in hospitalized patients. Mock codes and RRTs are another strategy for improving outcomes.The Corporal Michael J. Crescenz VA Medical Center(CMCVAMC) used data from the American Heart Association National Registry of Cardio-Pulmonary Resuscitation to create an interprofessional, collaborative program using simulation. The program included: review of emergency responses and hands-on sessions with crash cart equipment, airway management, and BLS skills, followed by a mock RRT and Code with debriefing. Participants in this quality improvement initiative were nurses, physicians, anesthetists, pharmacists, and respiratory therapists. They evaluated the simulation as a positive learning experience. Staff and patient outcomes were improved after the program. The program engaged staff and promoted interprofessional collaboration that may ultimately improve the quality of patient care.

E-CPR as a bridge for decision in the cath lab

Aim: Refractory cardiogenic shock (CS) complicates 5–7% of cases with ST-elevation myocardial infarction (STEMI), and is a leading cause of hospital death after myocardial infarction.1 CS complicating acute myocardial infarction (AMI) continues to have a high mortality of 40–50% despite early revascularization and adjunctive therapies.2 Extracorporeal membrane oxygenation (ECMO) technology has advanced significantly and is readily available at the bedside. This is a viable option for short-term support in the setting of acute cardiac ischemia. According to the 2003 USA National Registry of cardiopulmonary resuscitation (CPR), in-hospital cardiac arrest has a poor prognosis with an overall survival to hospital discharge rate of 17% with conventional CPR.3 One of the most common causes of cardiac arrest is ventricular fibrillation (VF) secondary to ischemia, which carries an improved prognosis if successfully defibrillated, with the rate of survival to hospital discharge being 34%.3 In cases with refractory ischemic VF, definitive therapy with percutaneous coronary intervention (PCI) may not be possible without anoxic brain injury secondary to hemodynamic collapse. CPR was introduced in the 1960s as a lifesaving method in patients with cardiac arrest.3 To supplement CPR in select patients, ECMO is used successfully for witnessed in-hospital cardiac arrest.3 In the setting of an AMI, bridging to a revascularization procedure is important in improving neurological outcome and overall survival. We report the profile and the outcome of patients in refractory VF resistant to defibrillation on ECMO support. Subsequent to revascularization, the patient's cardiac rhythm converted back to sinus rhythm with a single defibrillation shock with excellent neurological recovery. Methods: Since January 2014, we have been reviewing patients who had suffered from progressive severe refractory CS post STEMI undergoing emergency PCI on percutaneous veno-arterial (VA)-ECMO support. Results: For 11 male patients (mean age 50 ± 18 years), the mean duration of support was 7 ± 4 days. Of these patients, 9 (81%) were weaned successfully from ECMO. However, two patients on ECMO support died: one due to massive gastrointestinal bleeding and the other due to septic shock. Three other patients also died; one due to occluded stent on third day post-ECMO removal, one due to intracranial hemorrhage on second day post-ECMO removal, and one due to septic shock on fourth day post-ECMO removal. The 30-day survival was 54% (6/11 patients) without any neurological deficit. Conclusion: VA-ECMO has shown to be an option to bridge patients in CS and/or refractory VF to allow for a successful revascularization procedure and ultimately good neurological and survival outcome.

Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry

Objective To determine if earlier administration of epinephrine (adrenaline) in patients with non-shockable cardiac arrest rhythms is associated with increased return of spontaneous circulation, survival, and neurologically intact survival.Design Post...

Survival by the Fittest: Hospital‐Level Variation in Quality of Resuscitation Care

Despite several advances in resuscitation care over the last decade, in-hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20%

Intrahospital Dissemination of Automatic External Defibrillators Decrease Time to Defibrillation of In-Hospital Cardiac Arrests

Background: Survival rates for in-hospital cardiac (IHCA) arrest are low. Early defibrillation is vital and international guidelines, which requests defibrillation within three minutes. Can dissemination of automatic external defibrillators (AED) at hospital wards shorten time to defibrillation compared to standard care, calling for medical emergency team (MET)? Material & Methods: Forty-eight (48) units at S?dersjukhuset, Sweden, were included in the study. They were divided into the intervention group (24 units equipped with AEDs) and the standard care group (24 units with no AEDs). Intervention group staff were trained in CPR to use AEDs and standard care group staff were trained in just CPR. Data were gathered from patient records, AEDs and the Swedish National Registry of Cardiopulmonary Resuscitation (NRCR). Results: 126 IHCA patients were included, 47 in the standard care group, 79 in the intervention group. AEDs in the intervention group were connected to a defibrillator and it was ready to shock before arrival of MET in 83.5% of all cases. AEDs were ready to be used on average 96 seconds (14-427 s) before arrival of MET. Seven (15%) patients were defibrillated in the control group and Twenty (25%) in the intervention group. Defibrillation within three minutes occurred in 67% in the intervention group (11/17), compared with none (0/7) in the control group (p = 0.02). Conclusion: A systematic implementation of AEDs in hospital wards decrease time to defibrillation compared to a standard MET response system. Larger studies are needed to evaluate the impact on the outcome.

Care related in hospital cardiac arrest (CR-IHCA)—Incidence and outcome—A single center report

Introduction: Due to the considerable work of analysis of the National Registry of Cardiopulmonary resuscitation, knowledge about incidence and prognosis of In Hospital Cardiac Arrest (IHCA) has evolved recently. 1 Merchant R.M. Med Care. 2012; 50: 124-130 Crossref PubMed Scopus (26) Google Scholar , 2 Girotra S.N. Engl J Med. 2012; 367: 1912-1920 Crossref PubMed Scopus (522) Google Scholar , 3 Bradley S.M. Resuscitation. 2012; 83: 1349-1357 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Institution resources devoted to reduce IHCA mortality are increasing worldwide. Most strategies focus on either emergency team performance or pre-IHCA deterioration detection. While differences in outcome between care units and in-hospital location of IHCA is almost universally recognized, 4 Wallmuller C. Resuscitation. 2012; 83: 1206-1211 Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar incidence and prognosis of CR-IHCA remains an undisclosed issue. We analyzed our internal IHCA database to determine the incidence and outcome of CR-IHCA.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Early Detection of the Deteriorating Patient : The Case for a Multi-Parameter Patient-Worn Monitor

Scott McCombie, BSBSE, is research engineer at Sotera Wireless, San Diego, CA. E-mail: scott.mccombie@ soterawireless.com Effective, efficient, and safe delivery of healthcare is dependent on the timely identification and treatment of a deteriorating patient condition. Failure to rescue patients in the early stage of physiological deterioration can result in permanent organ injury, extended medical treatment, increased recovery time, or death. These avoidable adverse events drive healthcare costs up and quality down. The primary indicator of failure to rescue is unsuccessful cardiopulmonary resuscitation. The American Heart Association created a national registry of cardiopulmonary resuscitation (NPCPR) in 2000 as a voluntary evidence-based patient safety initiative. A review by Peberdy and colleagues of 14,720 cases of cardiopulmonary arrest from the NPCPR database collected between 2000 and 2002 shows the following breakdown of physiology, immediate cause, and discovery.

Abstract P197: Duration of Hospital Participation in Get With The Guidelines--Resuscitation and Survival of In-Hospital Cardiac Arrest

Background. Get With the Guidelines (GWTG)-Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation (NRCPR)) is a data registry and quality improvement program for in-hospital cardiac arrest (IHCA). It is unknown if duration of hospital participation in GWTG-Resuscitation is associated with IHCA outcomes. Methods. We analyzed 104,732 adult patients with IHCA from 362 hospitals participating in GWTG-Resuscitation between 2000 and 2009. The association between duration of hospital participation in GWTG-Resuscitation and patient outcomes after IHCA was determined with multiple logistic regression after adjusting for patient and hospital characteristics and secular trends by inclusion of calendar year. We also evaluated the association between duration of participation and factors previously correlated with survival after IHCA, including ECG monitored status, after-hours arrest, and time to defibrillation. All models were constructed as generalized estimating equations to account for clustering of patients at the hospital level. Results. Survival to discharge occurred in 17,646 patients (16.9%). Duration of hospital participation in GWTG-Resuscitation was weakly associated with improved IHCA outcomes (Table). Among factors correlated with IHCA survival, duration of participation was associated with time to defibrillation &lt; 2 minutes (per year of participation, OR 1.06; 95% CI 1.03-1.09; p&lt;0.001), but not ECG monitored status (OR 1.00; 95% CI 0.93-1.06; p=0.90) or survival of after-hours arrest (OR 1.01; 95% CI 0.99-1.03; p=0.41). Inclusion of time to defibrillation attenuated the association between duration of participation and outcomes of ventricular tachycardia or ventricular fibrillation (VT/VF) arrests. Conclusion. Duration of hospital participation in GWTG-Resuscitation is weakly associated with survival of IHCA. In VT/VF arrests, this association may be mediated by improvements in time to defibrillation. Survival by Duration of Hospital Participation in Get With the Guidelines-Resuscitation Odds-Ratio per Year of GWTG-Resuscitation Participation (95% CI) Unadjusted Model 1: Patient and Hospital Characteristics and Calendar Year Model 1 Plus ECG Monitored Model 1 Plus After-Hours Arrest Model 1 Plus Time to Defibrillation All Events Survival of event 1.06 (1.05-1.07) ‡ 1.02 (1.00-1.03) * 1.02 (1.00-1.04) * 1.02 (1.00-1.04) * N/A Survival to 24 hours 1.03 (1.02-1.04) ‡ 1.01 (0.99-1.03) 1.01 (0.99-1.03) 1.01 (0.99-1.03) Survival to discharge 1.03 (1.02-1.04) ‡ 1.02 (0.99-1.04) 1.02 (0.99-1.04) 1.02 (0.99-1.04) No major disability 1.04 (1.01-1.06) * 1.00 (0.96-1.05) 1.00 (0.96-1.05) 1.00 (0.96-1.05) VT/VF Arrest Events Survival of event 1.06 (1.04-1.08) ‡ 1.03 (1.00-1.05) * 1.03 (1.00-1.05) * 1.03 (1.00-1.05) * 1.01 (0.98-1.04) Survival to 24 hours 1.03 (1.01-1.05) † 1.01 (0.99-1.04) 1.01 (0.99-1.04) 1.01 (0.99-1.04) 1.00 (0.97-1.02) Survival to discharge 1.03 (1.01-1.05) † 1.01 (0.98-1.04) 1.01 (0.98-1.04) 1.01 (0.98-1.04) 1.00 (0.97-1.03) No major disability 1.03 (1.00-1.07) * 1.00 (0.95-1.05) 1.00 (0.95-1.05) 1.00 (0.95-1.05) 0.99 (0.94-1.04) All models were constructed as generalized estimating equations with independent correlation matrix and robust variance to account for clustering of patients at the hospital level. * p&lt;0.05; † p&lt;0.01; ‡ p&lt;0.001.

In-hospital cardiac arrest: Impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge

ContextIn-hospital cardiac arrest is a significant public health problem with a low probability of patient survival to hospital discharge. ObjectiveWe evaluated the survival rates for adults with in-hospital cardiac arrest based on whether the arrest was witnessed and/or monitored. Our hypothesis is that patients with either a witnessed or monitored arrest had improved survival to hospital discharge with intact neurologic function. Design, setting, and patientsWe studied a cohort study of 74,213 patients who suffered in-hospital cardiac arrest from January 1, 2000 through February 1, 2008 at the 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. InterventionsThe primary exposure of interest was whether the arrest was witnessed and/or monitored (i.e. electrocardiography, pulse oximetry, apnea, or bradycardia monitoring) at the time of arrest. Events were classified as being both monitored and witnessed, monitored only, witnessed only, or neither witnessed nor monitored. Main outcome measuresSurvival to hospital discharge and cerebral performance category at time of discharge. ResultsA total of 73% of patients suffering in-hospital cardiac arrest were witnessed and monitored; 10% were monitored but not witnessed; 9% were witnessed but not monitored; and 8% were neither witnessed nor monitored. Compared with those who were unmonitored/unwitnessed, each of the three groups of patients who were monitored and/or witnessed were over twice as likely to survive to hospital discharge with a cerebral performance category of 1 or 2 (monitored/witnessed OR=2.40, 95% CI: 2.08, 2.76; monitored-only OR=2.12, 95% CI: 1.81, 2.47; witnessed-only OR=2.43, 95% CI: 2.10, 2.83). ConclusionsPatients who are witnessed and/or monitored at the time of cardiac arrest demonstrate a significantly higher rate of survival to hospital discharge compared to those patients who are neither monitored nor witnessed. Monitored and/or witnessed cardiac arrest patients were also more likely to be discharged with favorable neurologic outcome. Cardiac monitoring confers no additional outcome benefit over direct observation of patients suffering in-hospital cardiac arrest.

Temperature patterns in the early postresuscitation period after pediatric inhospital cardiac arrest*

To describe the prevalence of postarrest hyperthermia among children during the first 24 hrs after inhospital cardiac arrest and to determine the association of persistent postarrest hyperthermia with neurologic outcome and death before hospital discharge. Multicenter, national registry of inhospital cardiopulmonary resuscitation. A total of 196 hospitals reporting to the American Heart Association's National Registry of Cardiopulmonary Resuscitation from January 1, 2005 to December 31, 2007. A total of 547 pediatric patients who suffered inhospital pulseless cardiac arrests reported to the National Registry of Cardiopulmonary Resuscitation, who survived resuscitative efforts and who had the maximum and the minimum temperature in the first 24 hrs postresuscitation reported to the National Registry of Cardiopulmonary Resuscitation. None. Among 547 children with pulseless cardiac arrests, 238 (43.5%) had at least one temperature of ≥38°C, and 30 (5.5%) had "persistent hyperthermia" (i.e., both the minimum and the maximum temperature of ≥38°C) during the first 24 hrs postarrest. After adjusting for potential confounders by multivariate logistic regression, persistent hyperthermia in the first 24 hrs postarrest was associated with unfavorable neurologic outcome (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-6.7), but not with death before hospital discharge (adjusted odds ratio, 1.2; 95% confidence interval, 0.4-3.4). Despite current guidelines to avoid postarrest hyperthermia, a temperature of ≥38°C occurred commonly among children in the first 24 hrs postarrest. Persistent postarrest hyperthermia was associated with unfavorable neurologic outcomes, even after controlling for potential confounding factors.

Part 4: CPR Overview

Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.1 Although the optimal approach to CPR may vary, depending on the rescuer, the victim, and the available resources, the fundamental challenge remains: how to achieve early and effective CPR. Given this challenge, recognition of arrest and prompt action by the rescuer continue to be priorities for the 2010 AHA Guidelines for CPR and ECC. This chapter provides an overview of cardiac arrest epidemiology, the principles behind each link in the Chain of Survival, an overview of the core components of CPR (see Table 1), and the approaches of the 2010 AHA Guidelines for CPR and ECC to improving the quality of CPR. The goal of this chapter is to integrate resuscitation science with real-world practice in order to improve the outcomes of CPR. View this table: Table 1. Summary of Key BLS Components for Adults, Children and Infants Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world.2 Cardiac arrest occurs both in and out of the hospital. In the US and Canada, approximately 350 000 people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation.3,–,7 This estimate does not include the substantial number of victims who suffer an arrest without attempted resuscitation. While attempted resuscitation is not always appropriate, there are many lives and life-years lost because appropriate resuscitation is not attempted. The estimated incidence of EMS-treated out-of-hospital cardiac arrest in the US and Canada is about 50 to 55/100 000 persons/year and approximately 25% of these present with pulseless ventricular arrhythmias.3,8 The estimated incidence of in-hospital cardiac arrest is 3 to 6/1000 admissions4,– …

Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Delayed Time to Defibrillation after Intraoperative and Periprocedural Cardiac Arrest

Delay in defibrillation (more than 2 min) is associated with worse survival in patients with a cardiac arrest because of ventricular fibrillation or pulseless ventricular tachycardia in intensive care units and inpatient wards. We tested the relationship between delayed defibrillation and survival from intraoperative or periprocedural cardiac arrest, adjusting for baseline patient characteristics. The analysis was based on data from 865 patients who had intraoperative or periprocedural cardiac arrest caused by ventricular fibrillation or pulseless ventricular tachycardia in 259 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. The median time to defibrillation was less than 1 min (interquartile range, <1 to 1 min). Delays in defibrillation occurred in 119 patients (13.8%). Characteristics associated with delayed defibrillation included pulseless ventricular tachycardia and noncardiac admitting diagnosis. The association between delayed defibrillation and survival to hospital discharge differed for periprocedural and intraoperative cardiac arrests (P value for interaction = 0.003). For patients arresting outside the operating room, delayed defibrillation was associated with a lower probability of surviving to hospital discharge (31.6% vs. 62.1%, adjusted odds ratio 0.49; 95% CI 0.27, 0.88; P = 0.018). In contrast, delayed defibrillation was not associated with survival for cardiac arrests in the operating room (46.8% vs. 39.6%, adjusted odds ratio 1.23, 95% CI 0.70, 2.19, P = 0.47). Delays in defibrillation occurred in one of seven cardiac arrests in the intraoperative and periprocedural arenas. Although delayed defibrillation was associated with lower rates of survival after cardiac arrests in periprocedural areas, there was no association with survival for cardiac arrests in the operating room.

Women of child-bearing age have better inhospital cardiac arrest survival outcomes than do equal-aged men*

Estrogen and progesterone improve neurologic outcomes in experimental models of cardiac arrest and stroke. Our objective was to determine whether women of child-bearing age are more likely than men to survive to hospital discharge after in-hospital cardiac arrest. Prospective, observational study. Five hundred nineteen hospitals in the National Registry of Cardiopulmonary Resuscitation database. Patients included 95,852 men and women 15-44 yrs and 56 yrs or older with pulseless cardiac arrests from January 1, 2000 through July 31, 2008. Patients were stratified a priori by gender and age groups (15-44 yrs and > or =56 yrs). Fixed-effects regression conditioning on hospital was used to examine the relationship between age, gender, and survival outcomes. The unadjusted survival to discharge rate for younger women of child-bearing age (15-44 yrs) was 19% (940/4887) vs. 17% (1203/7025) for younger men (p = .013). The adjusted hospital discharge difference between these younger women and men was 2.8% (95% confidence interval, 1.0% to 4.6%; p = .002), and these younger women also had a 2.6% (95% confidence interval, 0.9% to 4.3%; p = .002) absolute increase in favorable neurologic outcome. For older women compared with men (> or =56 yrs), there were no demonstrable differences in discharge rates (18% vs. 18%; adjusted difference, -0.1%; 95% confidence interval, -0.9% to 0.6%; p = .68) or favorable neurologic outcome (14% vs. 14%; adjusted difference, -0.1%; 95% confidence interval, -0.7% to 0.5%; p = .74). Women of child-bearing age were more likely than comparably aged men to survive to hospital discharge after in-hospital cardiac arrest, even after controlling for etiology of arrest and other important variables.

Outcomes of Critically Ill Patients Who Received Cardiopulmonary Resuscitation

Studies examining survival outcomes after in-hospital cardiopulmonary arrest (CPA) among intensive care unit (ICU) patients requiring medications for hemodynamic support are limited. To examine outcomes of ICU patients who received cardiopulmonary resusitation. We identified 49,656 adult patients with a first CPA occurring in an ICU between January 1, 2000 and August 26, 2008 within the National Registry of Cardiopulmonary Resuscitation. Survival outcomes of patients requiring hemodynamic support immediately before CPA were compared with those of patients who did not receive hemodynamic support (pressors), using multivariable logistic regression analyses to adjust for differences in demographics and clinical characteristics. Pressor medications included epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, and vasopressin. The overall rate of survival to hospital discharge was 15.9%. Patients taking pressors before CPA were less likely to survive to discharge (9.3 vs. 21.2%; P < 0.0001). After multivariable adjustment, patients taking pressors before pulseless CPA were 55% less likely to survive to discharge (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.42-0.48). Age equal to or greater than 65 years (adjusted OR, 0.77; 95% CI, 0.73-0.82), nonwhite race (adjusted OR, 0.58; 95% CI, 0.54-0.62), and mechanical ventilation (adjusted OR, 0.60; 95% CI, 0.56-0.63) were also variables that could be identified before CPA that were independently associated with lower survival. More than half of survivors were discharged to rehabilitation or extended care facilities. Only 3.9% of patients who had CPA despite pressors were discharged home from the hospital, as compared with 8.5% of patients with a CPA and not taking pressors (adjusted OR, 0.53; 95% CI, 0.49-0.59). Although overall survival of ICU patients was 15.9%, patients requiring pressors and who experienced a CPA in an ICU were half as likely to survive to discharge and to be discharged home than patients not taking pressors. This study provides robust estimates of CPR outcomes of critically ill patients, and may assist clinicians to inform consent for this procedure.

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.

Time to invasive airway placement and resuscitation outcomes after inhospital cardiopulmonary arrest

Background Clinicians often place high priority on invasive airway placement during cardiopulmonary resuscitation. The benefit of early vs. later invasive airway placement remains unknown. In this study we examined the association between time to invasive airway (TTIA) placement and patient outcomes after inhospital cardiopulmonary arrest (CPA). Methods We analyzed data from the National Registry of Cardiopulmonary Resuscitation (NRCPR). We included hospitalized adult patients receiving attempted invasive airway placement (endotracheal intubation, laryngeal mask airway, tracheostomy, and cricothyrotomy) after the onset of CPA. We excluded cases in which airway insertion was attempted after return of spontaneous circulation (ROSC). We defined TTIA as the elapsed time from CPA recognition to accomplishment of an invasive airway. The primary outcomes were ROSC, 24-h survival, and survival to hospital discharge. We used multivariable logistic regression to evaluate the association between the patient outcome and early (<5 min) vs. later (≥5 min) TTIA, adjusted for hospital location, patient age and gender, first documented pulseless ECG rhythm, precipitating etiology and witnessed arrest. Results Of 82,649 CPA events, we studied the 25,006 cases in which TTIA was recorded and the inclusion criteria were met. Observations were most commonly excluded for not having an invasive airway emergently placed during resuscitation. The mean time to invasive airway placement was 5.9 min (95% CI: 5.8–6.0). Patient outcomes were: ROSC 50.3% (49.7–51.0%), 24-h survival 33.7% (33.1–34.3%), survival to discharge 15.3% (14.9–15.8%). Early TTIA was not associated with ROSC (adjusted OR: 0.96, 0.91–1.01) but was associated with better odds of 24-h survival (adjusted OR: 0.94, 0.89–0.99). The relationships between TTIA and survival to discharge could not be determined. Conclusions Early invasive airway insertion was not associated with ROSC but was associated with slightly improved 24-h survival. Early invasive airway management may or may not improve inhospital cardiopulmonary resuscitation outcomes.

Cardiopulmonary Resuscitation for Bradycardia With Poor Perfusion Versus Pulseless Cardiac Arrest

The objective of this study was to assess whether pediatric inpatients who receive cardiopulmonary resuscitation (CPR) for bradycardia with poor perfusion are more likely to survive to hospital discharge than pediatric inpatients who receive CPR for pulseless arrest (asystole/pulseless electrical activity [PEA]), after controlling for confounding characteristics. A prospective cohort from the National Registry of Cardiopulmonary Resuscitation was enrolled between January 4, 2000, and February 23, 2008. Patients who were younger than 18 years and had an in-hospital event that required chest compressions for >2 minutes were eligible. Patients were divided into 2 groups on the basis of initial rhythm and pulse state: bradycardia/poor perfusion and asystole/PEA. Patient characteristics, event characteristics, and clinical characteristics were analyzed as possible confounders. Univariate analysis between bradycardia and asystole/PEA patient groups was performed. Multivariable logistic regression was used to determine whether an initial state of bradycardia/poor perfusion was independently associated with survival to discharge. A total of 6288 patients who were younger than 18 years were reported; 3342 met all inclusion criteria. A total of 1853 (55%) patients received chest compressions for bradycardia/poor perfusion compared with 1489 (45%) for asystole/PEA. Overall, 755 (40.7%) of 1353 patients with bradycardia survived to hospital discharge, compared with 365 (24.5%) of 1489 patients with asystole/PEA. After controlling for known confounders, CPR for bradycardia with poor perfusion was associated with increased survival to hospital discharge. Pediatric inpatients with chest compressions initiated for bradycardia and poor perfusion before onset of pulselessness were more likely to survive to discharge than pediatric inpatients with chest compressions initiated for asystole or PEA.

Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory in-hospital pediatric cardiac arrest: A report from the National Registry of CardioPulmonary Resuscitation*

Describe the use of extracorporeal cardiopulmonary resuscitation as rescue therapy in pediatric patients who experience cardiopulmonary arrest refractory to conventional resuscitation. We report on outcomes and factors associated with survival in children treated with extracorporeal cardiopulmonary resuscitation during cardiopulmonary arrest from the American Heart Association National Registry of CardioPulmonary Resuscitation. Multicentered, national registry of in-hospital cardiopulmonary resuscitation. Two hundred eighty-five hospitals reporting to the registry from January 2000 to December 2007. Pediatric patients <18 yrs of age who received extracorporeal membrane oxygenation during cardiopulmonary resuscitation for in-hospital cardiopulmonary arrest. None. Prearrest and arrest variables were collected. The primary outcome variable was survival to hospital discharge. The secondary outcome was neurologic status after extracorporeal cardiopulmonary resuscitation at hospital discharge. Favorable neurologic outcome was defined as Pediatric Cerebral Performance Categories 1, 2, 3, or no change from admission Pediatric Cerebral Performance Category. Of 6288 pediatric cardiopulmonary arrest events reported, 199 (3.2%) index extracorporeal cardiopulmonary resuscitation events were identified; 87 (43.7%) survived to hospital discharge. Fifty-nine survivors had Pediatric Cerebral Performance Category outcomes recorded, and of those, 56 (94.9%) had favorable outcomes. In a multivariable model, the prearrest factor of renal insufficiency and arrest factors of metabolic or electrolyte abnormality and the pharmacologic intervention of sodium bicarbonate/tromethamine were associated with decreased survival. After adjusting for confounding factors, cardiac illness category was associated with an increased survival to hospital discharge. Forty-four percent of pediatric patients who failed conventional cardiopulmonary resuscitation from in-hospital cardiopulmonary arrest and who were reported to the National Registry of CardioPulmonary Resuscitation database as treated with extracorporeal cardiopulmonary resuscitation survived to hospital discharge. The majority of survivors with recorded neurologic outcomes were favorable. Patients with cardiac illness category were more likely to survive to hospital discharge after treatment with extracorporeal cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation should be considered for select pediatric patients refractory to conventional in-hospital resuscitation measures.