Pediatric Cardiac Arrest Research Articles

Abstract 317: Brain MRI And Spectroscopy Biomarkers Predict Outcome After Pediatric Cardiac Arrest In POCCA

Conventional (T2) and diffusion-weighted imaging (DWI) on brain magnetic resonance imaging (MRI) and lactate and N-acetyl-aspartate (NAA) on MR spectroscopy (MRS) can characterize brain hypoxic-ischemic injury. We hypothesized these neuroimaging biomarkers would be associated with 1 year outcome after pediatric cardiac arrest in a multicenter, observational study. Fourteen US centers enrolled children aged < 18 years with pediatric intensive care unit admission post-arrest if pre- arrest Pediatric Cerebral Performance Category score was 1-3. Brain MRI/MRS performed within 2 weeks post-arrest were analyzed independently by 2 pediatric neuroradiologists blinded to outcome. MRI lesions on T2 and DWI were scored by region and severity (0=none, 1=mild, 2=moderate, 3=severe). Total MRI score was a sum of T2 and DWI lesions in gray and white matter (max 34). Lactate and NAA were measured in the basal ganglia, thalamus, and occipital-parietal white/gray matter and quantified by LCModel. Multivariate regression was performed to determine the association with unfavorable outcome (Vineland Adaptive Behavioral Scale < 70 or dead at 1 year). Of 164 children, 66 and 32 had evaluable MRI and MRS data and 23 (35%) and 12 (38%) had unfavorable outcome, respectively. Children with unfavorable outcome had more unwitnessed and out-of-hospital events. DWI lesions in all 4 lobes predicted unfavorable outcome, whereas T2 temporal gray and parietal white matter lesions predicted unfavorable outcome, p<0.05. T2/DWI lesions in the basal ganglia, thalamus, and centrum semi-ovale predicted unfavorable outcome, p<0.05. Cerebellar/ brain stem white matter lesions predicted unfavorable outcome, p<.05. Total MRI scores were markedly higher in the unfavorable group (median [interquartile range]) (22 [7, 32] vs. 1 [0,8], p<0.001). Increased lactate and decreased NAA predicted unfavorable outcome in all 4 regions of interest, p<0.05. In a multivariate logistic regression, MRI total score (odds ratio 1.12 [95% confidence interval 1.05, 1.20]) and witnessed event status (0.07 [0.01, 0.34]) predicted outcome. Brain MRI and MRS biomarkers are useful to identify children with unfavorable outcome within 2 weeks post-cardiac arrest.

Abstract 265: Social Determinants Of Health Impact Phenotype-based Outcome Prediction After Pediatric Arrest

The Personalizing Outcomes after Child Cardiac Arrest-1 (POCCA-1) trial showed that blood-based brain injury biomarkers have promise to prognosticate outcome post-pediatric cardiac arrest. However, whether POCCA-1 biomarkers perform accurately among all children is unknown. Hypothesis We hypothesized that POCCA-1 biomarkers will have different performance accuracy by distinct clinical phenotypes after pediatric cardiac arrest. Methods: Fourteen US centers enrolled 164 children aged < 18 y with pediatric intensive care unit admission post-arrest. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1, neurofilament light, and Tau proteins were measured in blood post-arrest d1-3. Patient ZIP codes linked to US census data provided socioeconomic neighborhood characteristics. We analyzed 120 children with evaluable data (n=50, unfavorable outcome [Vineland Adaptive Behavioral Scale < 70 or dead]) to create 3 clinical phenotypes using latent class analysis. POCCA-1 biomarker levels and outcomes were analyzed by phenotype. The POCCA-1 model was analyzed to predict 1 y unfavorable outcome using multivariate AUROC by phenotype for all 4 biomarkers on d1- 3 post-arrest. Results: Group 1 (n=35, 22%) were older, of White race, with private insurance and out-of-hospital cardiac arrests (OOHCA), fewer fever post-arrest, living in neighborhoods of mostly White race and lower poverty. Group 2 patients (n=77, 47%) were younger, of White race, with in-hospital cardiac arrests living in more socioeconomically diverse neighborhoods. Group 3 (n=51, 31%) were diverse in race and age, of more male sex, with Medicaid insurance and asphyxial, OOHCA, living in more impoverished neighborhoods. Unfavorable outcome was higher in Group 3 (69%) vs 1 (48%) and 2 (28%), p<0.001. All biomarkers (except Tau) were significantly increased on d1-3 in Group 3. Biomarker accuracy to predict outcome was excellent for Group 1 with 11/12 AUROCs significant. Models were less accurate for Group 2 (7/12) and marginal for Group 3 (3/12). Conclusions: The POCCA-1 prediction model performance varied by patient, arrest, and neighborhood context, suggesting that prediction models need to be personalized using clinically relevant and equitable phenotypes.

Abstract 287: Trends In Cardiac Arrest Outcomes In Children With Cardiac Disease: An Analysis From The Aha Get With The Guidelines ® Database

Introduction: Contemporary rates of survival after pediatric in-hospital cardiac arrest (IHCA) and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that (1) survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and (2) rates of survival after IHCA increased over time in all categories. Methods: The AHA Get With The Guidelines ® -Resuscitation database was queried for index IHCA events (excluding delivery room and neonatal intensive care unit) in children <18 years of age from 2000-2021. Categories were defined as: surgical-cardiac, IHCA following cardiac surgery; medical-cardiac, IHCA in non-surgical cardiac disease; and non-cardiac, IHCA in patients without cardiac disease. The primary outcome was survival to hospital discharge. We compared eras 2000-2004, 2005-2009, 2010-2014, and 2015-2021 with mixed logistic regression models, including event year as a continuous predictor and site as a random effect. Results: Of 17,696 index events, IHCA by illness category were: 18% surgical-cardiac, 18% medical-cardiac, and 64% non-cardiac. Surgical-cardiac category had the highest rate of survival to discharge compared to medical-cardiac and non-cardiac categories (56.1% vs. 43.4% vs. 46.3%; p<0.001). After controlling for age, location of event, and hospital size, the odds of survival were higher for surgical-cardiac category (aOR 1.28 (1.16, 1.40)) and lower for medical-cardiac category (aOR 0.87 (0.80, 0.95)), compared to the non-cardiac category. Odds of survival increased for all illness categories across eras. Between the 2000-2004 and 2015-2021 eras, survival in surgical-cardiac subjects increased from 45.6% to 62.3% with odds of survival increasing by 24% per era, (OR 1.24 (95% CI 1.15, 1.35), and survival for medical-cardiac subjects increased from 36.6% to 47.0%, with 14% increased odds per era (OR 1.14 (1.06, 1.23)). Conclusions: Over the last 20 years, children with surgical-cardiac IHCA have substantially higher odds of survival to hospital discharge compared to non-cardiac IHCA categories, whereas odds of survival were worse with medical-cardiac IHCA. Survival to hospital discharge has increased in all IHCA illness categories.

Abstract 03: Early Post-Cardiac Arrest Blood Pressure Thresholds Associated with Outcomes: A Secondary Analysis of the ICU-Resuscitation Trial

Introduction: Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that maintaining BPs greater than the newly identified post-arrest systolic and diastolic BP thresholds early after IHCA are associated with higher rates of survival to hospital discharge. Methods: We performed a secondary analysis of prospectively collected BP data from the first six hours following index IHCA events enrolled in the ICU-Resuscitation trial. The lowest documented systolic BP (SBP) and diastolic BP (DBP) 0-6 hours post-arrest were categorized by age-based percentiles. After controlling for illness category and presence of pre-arrest hypotension (systolic or mean arterial blood pressure <5 th percentile-for-age or vasoactive/inotropic requirement), cubic spline analyses were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Clinical judgement and visual assessment of the spline curves were used to identify BP thresholds. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. Results: Among 693 index events with 0-6 hour post-arrest BP data, identified thresholds were: SBP >10 th percentile and DBP >50 th percentile for age. Fifty-one percent (n=352) of subjects had lowest SBP above threshold, 50% (n=346) had DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP aRR 1.21; 95% CI 1.10, 1.33; DBP aRR 1.23; 1.12, 1.34) and favorable neurologic outcome (SBP aRR 1.22; 1.10, 1.35; DBP aRR 1.27; 1.15, 1.40) (all p<0.001). Conclusions: These data establish that SBP >10 th percentile-for-age and DBP >50 th percentile-for-age during the first 6 hours post-arrest were associated with higher rates of survival to hospital discharge and favorable neurologic outcome.

Abstract 211: Epinephrine Does Not Correct Post-ROSC Hypoperfusion Despite Normalizing Blood Pressure A Rat Model Of Severe Pediatric Asphyxial Cardiac Arrest

In children resuscitated from cardiac arrest, systemic hypotension occurs frequently and is associated with worse outcome. The first-line vasoactive treatment for post-arrest hypotension is continuous infusion of epinephrine. Epinephrine dose is titrated to maintain normal blood pressure for age. Epinephrine, however, also leads to vasoconstriction which may impair organ perfusion after resuscitation.We hypothesized that epinephrine infusion during the post-resuscitation period restores systemic blood pressure but not flow to vital organs. Using a model of severe pediatric asphyxial cardiac arrest in developing rats, we simultaneously measured blood pressure (ABP) and flow in carotid (Fc) and femoral (Ff) arteries after resuscitation. We then compared the effects of epinephrine or saline infusions on blood pressure vs flow. One hour after resuscitation from 11.5 minutes of asphyxial arrest, ABP, Fc and Ff were 61.73 ± 2.68; 42.58 ± 3.84; and 19.53 ± 7.00 % of baseline. Epinephrine infusion increased ABP in a dose-dependent manner, reaching 95.13 ± 7.93 % of baseline at 0.5 μg/kg/min. Saline infusion at equivalent volumes increased ABP only marginally to 69.88 ± 2.60 % of baseline. In contrast to its effect on ABP, epinephrine infusion increased Fc only to 49.55 ± 6.49 and Ff to 53.28 ± 7.13 % of baseline. Saline infusion at equivalent volumes, on the other hand, had a more salutary effect than epinephrine on improving blood flow (Fc 64.62 ± 6.64 and Ff 60.25 ± 7.60 % of baseline). Notably, a single 10 cc/kg saline bolus, administered when ABP decreased to ~80% of baseline post-ROSC, increased blood flow and ABP to 100% and 90% of baseline, respectively. These data indicate that epinephrine infusion in the post-arrest period adversely affects arterial blood flow despite normalizing arterial blood pressure. Continued fluid resuscitation with crystalloids potentially has beneficial effect on correcting post-ROSC hypoperfusion. Future studies need to explore the impact of targeting flow rather than blood pressure in the post-arrest period and its association to post-arrest end-organ function in children.

Abstract 04: Chest Compressions Superimposed With Sustained Inflations Compared to Continuous Chest Compressions with Asynchronized Ventilation During Cardiopulmonary Resuscitation in Asphyxiated Pediatric Piglets - A Randomized Controlled Animal Study

Introduction: Respiratory arrest is the leading cause of pediatric cardiac arrest. Pediatric CRP guidelines therefore focus on respiratory support during CPR, but the optimal approach to oxygen delivery and coronary perfusion during pediatric CPR is not known. Animal studies reported that chest compressions superimposed with constant high distending pressure, or sustained inflation (CC+SI), significantly reduces time to return of spontaneous circulation (ROSC) compared to 3:1 chest compression:ventilation in neonatal piglets or chest compressions with asynchronous ventilation (CCaV) in pediatric piglets. During CC+SI, both cardiovascular and respiratory parameters were improved, which resulted in the faster time to ROSC. Hypothesis: In the current study, we hypothesized that CC+SI, compared to CCaV, would reduce time to ROSC in pediatric piglets with asphyxia-induced cardiac arrest. Methods: Twenty-eight pediatric piglets (21-24 days old, 7.5-9.2 kg) were anesthetized, intubated, instrumented, and exposed to 30 min normocapnic hypoxia followed by asphyxia. Piglets were then randomized to, and received, either CC+SI or CCaV for resuscitation (n=14 per group). Resuscitative efforts were continued until ROSC was achieved, or up to a maximum of 10 min. Hemodynamic parameters were monitored throughout the experiment and up to 30 min post-ROSC. Results and Conclusions: Overall, the mean (SD) time to ROSC was 208 (190) sec with CC+SI and 388 (258) sec with CCaV (p=0.045) (Table 1). There was a 100% increase in the number of piglets achieving ROSC with CC+SI compared to CCaV (CC+SI n=12 versus CCaV n=6, p=0.046). Median minute ventilation in the CC+SI group was 2,315 mL/min compared with 354 mL/min in the CCaV group (p=0.0001). Both systolic and diastolic blood pressure were higher in the CC+SI group, compared to the CCaV group throughout resuscitation. In summary, CC+SI improved time to ROSC and increased the number of piglets achieving ROSC. There was significantly higher minute ventilation with CC+SI, compared to CCaV, and both systolic and diastolic blood pressure were higher throughout resuscitation with CC+SI compared to CCaV. Studies in pediatric patients using CC+SI are warranted.

Limbic pathway vulnerability associates with neurologic outcome in children after cardiac arrest

AimTo analyze whether brain connectivity sequences including diffusion tensor imaging (DTI) and resting state functional magnetic resonance imaging (rsfMRI) identify vulnerable brain regions and networks associated with neurologic outcome after pediatric cardiac arrest. MethodsChildren aged 2 d-17 y with cardiac arrest were enrolled in one of 2 parent studies at a single center. Clinically indicated brain MRI with DTI and rsfMRI and performed within 2 weeks after arrest were analyzed. Tract-wise fractional anisotropy (FA) and axial, radial, and mean diffusivity assessed DTI, and functional connectivity strength (FCS) assessed rsfMRI between outcome groups. Unfavorable neurologic outcome was defined as Pediatric Cerebral Performance Category score 4–6 or change > 1 between 6 months after arrest vs baseline. ResultsAmong children with DTI (n = 28), 57% had unfavorable outcome. Mean, radial, axial diffusivity and FA of varying direction of magnitude in the limbic tracts, including the right cingulum parolfactory, left cingulum parahippocampal, corpus callosum forceps major, and corpus callosum forceps minor tracts, were associated with unfavorable neurologic outcome (p < 0.05). Among children with rsfMRI (n = 12), 67% had unfavorable outcome. Decreased FCS in the ventromedial and dorsolateral prefrontal cortex, insula, precentral gyrus, anterior cingulate, and inferior parietal lobule were correlated regionally with unfavorable neurologic outcome (p < 0.05 Family-Wise Error corrected). ConclusionDecreased multimodal connectivity measures of paralimbic tracts were associated with unfavorable neurologic outcome after pediatric cardiac arrest. Longitudinal analysis correlating brain connectivity sequences with long term neuropsychological outcomes to identify the impact of pediatric cardiac arrest in vulnerable brain networks over time appears warranted.

TriService Nursing Research Program: A critical component to support military nursing science

TriService Nursing Research Program: A critical component to support military nursing science

Early coagulopathy after pediatric out-of-hospital cardiac arrest: secondary analysis of a randomized clinical trial

BackgroundTo estimate the incidence, risk factors, and impact on mortality and functional outcomes for early coagulopathy after the return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) patients.MethodsA post hoc analysis of the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital (THAPCA-OH) trial was conducted. Early coagulopathy was defined as presence of at least one of the following coagulation abnormalities upon admission: international standard ratio (INR), platelets, and age-adjusted activated partial thromboplastin time (APTT) within 6 h after OHCA and before therapeutic hypothermia initiation. The outcomes included 28-day mortality and functional prognosis. Multivariable logistic regression models were used to explore risk factors and association between early coagulopathy and outcomes.ResultsOf the 227 patients included, 152 (67%) were male and the median age was 2.3 years [interquartile range (IQR), 0.7–8.6 years]. The overall 28-day mortality was 63%. The incidence of early coagulopathy was 46%. Lower age, longer duration of chest compression, lower temperature, and higher white blood cell (WBC) upon admission increased the risk of early coagulopathy. Early coagulopathy [OR, 2.20 (95% CI, 1.12–4.39), P = 0.023] was independently associated with 28-day mortality after adjusting for confounders.ConclusionsEarly coagulopathy occurred in almost half of pediatric patients with OHCA. Lower age, longer duration of chest compression, lower temperature, and higher WBC increased the risk. The development of early coagulopathy was independently associated with increased mortality.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

Association of Blood-Based Brain Injury Biomarker Concentrations With Outcomes After Pediatric Cardiac Arrest

Families and clinicians have limited validated tools available to assist in estimating long-term outcomes early after pediatric cardiac arrest. Blood-based brain-specific biomarkers may be helpful tools to aid in outcome assessment. To analyze the association of blood-based brain injury biomarker concentrations with outcomes 1 year after pediatric cardiac arrest. The Personalizing Outcomes After Child Cardiac Arrest multicenter prospective cohort study was conducted in pediatric intensive care units at 14 academic referral centers in the US between May 16, 2017, and August 19, 2020, with the primary investigators blinded to 1-year outcomes. The study included 120 children aged 48 hours to 17 years who were resuscitated after cardiac arrest, had pre-cardiac arrest Pediatric Cerebral Performance Category scores of 1 to 3 points, and were admitted to an intensive care unit after cardiac arrest. Cardiac arrest. The primary outcome was an unfavorable outcome (death or survival with a Vineland Adaptive Behavior Scales, third edition, score of <70 points) at 1 year after cardiac arrest. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCH-L1), neurofilament light (NfL), and tau concentrations were measured in blood samples from days 1 to 3 after cardiac arrest. Multivariate logistic regression and area under the receiver operating characteristic curve (AUROC) analyses were performed to examine the association of each biomarker with outcomes on days 1 to 3. Among 120 children with primary outcome data available, the median (IQR) age was 1.0 (0-8.5) year; 71 children (59.2%) were male. A total of 5 children (4.2%) were Asian, 19 (15.8%) were Black, 81 (67.5%) were White, and 15 (12.5%) were of unknown race; among 110 children with data on ethnicity, 11 (10.0%) were Hispanic, and 99 (90.0%) were non-Hispanic. Overall, 70 children (58.3%) had a favorable outcome, and 50 children (41.7%) had an unfavorable outcome, including 43 deaths. On days 1 to 3 after cardiac arrest, concentrations of all 4 measured biomarkers were higher in children with an unfavorable vs a favorable outcome at 1 year. After covariate adjustment, NfL concentrations on day 1 (adjusted odds ratio [aOR], 5.91; 95% CI, 1.82-19.19), day 2 (aOR, 11.88; 95% CI, 3.82-36.92), and day 3 (aOR, 10.22; 95% CI, 3.14-33.33); UCH-L1 concentrations on day 2 (aOR, 11.27; 95% CI, 3.00-42.36) and day 3 (aOR, 7.56; 95% CI, 2.11-27.09); GFAP concentrations on day 2 (aOR, 2.31; 95% CI, 1.19-4.48) and day 3 (aOR, 2.19; 95% CI, 1.19-4.03); and tau concentrations on day 1 (aOR, 2.44; 95% CI, 1.14-5.25), day 2 (aOR, 2.28; 95% CI, 1.31-3.97), and day 3 (aOR, 2.04; 95% CI, 1.16-3.57) were associated with an unfavorable outcome. The AUROC models were significantly higher with vs without the addition of NfL on day 2 (AUROC, 0.932 [95% CI, 0.877-0.987] vs 0.871 [95% CI, 0.793-0.949]; P = .02) and day 3 (AUROC, 0.921 [95% CI, 0.857-0.986] vs 0.870 [95% CI, 0.786-0.953]; P = .03). In this cohort study, blood-based brain injury biomarkers, especially NfL, were associated with an unfavorable outcome at 1 year after pediatric cardiac arrest. Additional evaluation of the accuracy of the association between biomarkers and neurodevelopmental outcomes beyond 1 year is needed.

Association Between Quantitative Diffusion-Weighted Magnetic Resonance Neuroimaging and Outcome After Pediatric Cardiac Arrest.

Diffusion MRI can quantify the extent of hypoxic-ischemic brain injury after cardiac arrest. Our objective was to determine the association between the adult-derived threshold of apparent diffusion coefficient (ADC) <650 × 10-6 mm2/s in >10% of brain tissue and an unfavorable outcome after pediatric cardiac arrest. Since ADC decreases exponentially as a function of increasing age, we determined the association between (1) having >10% of brain tissue below a novel age-dependent ADC threshold, and (2) age-normalized whole-brain mean ADC and unfavorable outcome. This was a retrospective study of patients aged ≤18 years who had cardiac arrest and a clinically obtained brain MRI within 7 days. The primary outcome was unfavorable neurologic status at hospital discharge based on the Pediatric Cerebral Performance Category score. ADC images were extracted from 3-direction diffusion imaging. We determined whether each patient had >10% of voxels with an ADC below prespecified thresholds. We computed the whole-brain mean ADC for each patient. One hundred thirty-four patients were analyzed. Patients with ADC <650 × 10-6 mm2/s in >10% of voxels had 15 times higher odds (95% CI 5-65) of an unfavorable outcome compared with patients with ADC <650 × 10-6 mm2/s (area under the receiver operating characteristic curve [AUROC] 0.72 [95% CI 0.63-0.80]). These ADC criteria had a sensitivity and specificity of 0.49 and 0.94, respectively, and positive and negative predictive values of 0.93 and 0.52, respectively, for an unfavorable outcome. The age-dependent ADC threshold that yielded optimal sensitivity and specificity for unfavorable outcomes was <300 × 10-6 mm2/s below each patient's predicted whole-brain mean ADC. The sensitivity, specificity, and positive and negative predictive values for this ADC threshold were 0.53, 0.96, 0.96, and 0.54, respectively (odds ratio [OR] 26.4 [95% CI 7.5-168.3]; AUROC 0.74 [95% CI 0.66-0.83]). Lower age-normalized whole-brain mean ADC was also associated with an unfavorable outcome (OR 0.42 [0.24-0.64], AUROC 0.76 [95% CI 0.66-0.82]). Quantitative diffusion thresholds on MRI within 7 days after cardiac arrest were associated with an unfavorable outcome in children. The age-independent ADC threshold was highly specific for predicting an unfavorable outcome. However, the specificity and sensitivity increased when using age-dependent ADC thresholds. Age-dependent ADC thresholds may improve prognostic accuracy and require further investigation in larger cohorts. This study provides Class III evidence that quantitative diffusion-weighted imaging within 7 days postarrest can predict an unfavorable clinical outcome in children.

Pediatic code blue event anaylsis: Performance of non-acute health-care providers

ABSTRACT In-hospital pediatric cardiopulmonary arrest is rare. With more than 50% of patients not surviving to discharge following cardiopulmonary arrest, it is important that health-care providers (HCPs) respond appropriately to deteriorating patients. Our study evaluated the performance of basic life support skills using non-acute HCPs during pediatric inpatient resuscitation events. We conducted a retrospective chart review of all code blue team (CBT) activations in non-acute care areas of a tertiary care children’s hospital from 2008 to 2017. The main outcomes were frequency of life support algorithmic assessments and interventions (critical actions) performed by non-acute HCPs prior to the arrival of CBT. CBT activation and outcome data were summarized descriptively. Logistic regression was used to assess for an association of outcomes with the presence of established leadership. A total of 60 CBT activations were retrieved, 48 of which had data available on isolated non-acute HCP performance. Most children (93%) survived to discharge. Critical action performance review revealed that an airway, breathing and pulse assessment was documented to have occurred in 33%, 69% and 29% of cases, respectively. A full primary assessment was documented in 6% of cases. The presence of established leadership was associated with the performance of a partial ABC assessment. Our results suggest that resuscitation performance of pediatric inpatient non-acute HCPs often does not adhere to standard life support guidelines. These results highlight the need to reconsider the current approaches used for non-acute HCP resuscitation training.

Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial.

To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. None. Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.

Resuscitation with epinephrine worsens cerebral capillary no-reflow after experimental pediatric cardiac arrest: An in vivo multiphoton microscopy evaluation

Epinephrine is the principal resuscitation therapy for pediatric cardiac arrest (CA). Clinical data suggest that although epinephrine increases the rate of resuscitation, it fails to improve neurological outcome, possibly secondary to reductions in microvascular flow. We characterized the effect of epinephrine vs. placebo administered at resuscitation from pediatric asphyxial CA on microvascular and macrovascular cortical perfusion assessed using in vivo multiphoton microscopy and laser speckle flowmetry, respectively, and on brain tissue oxygenation (PbO2), behavioral outcomes, and neuropathology in 16–18-day-old rats. Epinephrine-treated rats had a more rapid return of spontaneous circulation and brisk immediate cortical reperfusion during 1–3 min post-CA vs. placebo. However, at the microvascular level, epinephrine-treated rats had penetrating arteriole constriction and increases in both capillary stalling (no-reflow) and cortical capillary transit time 30–60 min post-CA vs. placebo. Placebo-treated rats had increased capillary diameters post-CA. The cortex was hypoxic post-CA in both groups. Epinephrine treatment worsened reference memory performance vs. shams. Hippocampal neuron counts did not differ between groups. Resuscitation with epinephrine enhanced immediate reperfusion but produced microvascular alterations during the first hour post-resuscitation, characterized by vasoconstriction, capillary stasis, prolonged cortical transit time, and absence of compensatory cortical vasodilation. Targeted therapies mitigating the deleterious microvascular effects of epinephrine are needed.

Paediatric chest compression performance improves via novel augmented-reality cardiopulmonary resuscitation feedback system: A mixed-methods pilot study in a simulation-based setting

AimMore than 20,000 children experience a cardiac arrest event each year in the United States. Most children do not survive. High-quality cardiopulmonary resuscitation (CPR) has been associated with improved outcomes yet adherence to guidelines is poor. We developed and tested an augmented reality head mounted display chest compression (CC) feedback system (AR-CPR) designed to provide real-time CC feedback and guidance. MethodsWe conducted an unblinded randomized crossover simulation-based study to determine whether AR-CPR changes a user's CC performance. A convenience sample of healthcare providers who perform CC on children were included. Subjects performed three two-minute cycles of CC during a simulated 18-minute paediatric cardiac arrest. Subjects were randomized to utilize AR-CPR in the second or third CC cycle. After, subjects participated in a qualitative portion to inquire about their experience with AR-CPR and offer criticisms and suggestions for future development. ResultsThere were 34 subjects recruited. Sixteen subjects were randomly assigned to have AR-CPR in cycle two (Group A) and 18 subjects were randomized to have AR-CPR in cycle three (Group B). There were no differences between groups CC performance in cycle one (baseline). In cycle two, subjects in Group A had 73% (SD 18%) perfect CC epochs compared to 17% (SD 26%) in Group B (p < 0.001). Overall, subjects enjoyed using AR-CPR and felt it improved their CC performance. ConclusionThis novel AR-CPR feedback system showed significant CC performance change closer to CC guidelines. Numerous hardware, software, and user interface improvements were made during this pilot study.

Low frequency power in cerebral blood flow is a biomarker of neurologic injury in the acute period after cardiac arrest

AimCardiac arrest often results in severe neurologic injury. Improving care for these patients is difficult as few noninvasive biomarkers exist that allow physicians to monitor neurologic health. The amount of low-frequency power (LFP, 0.01–0.1 Hz) in cerebral haemodynamics has been used in functional magnetic resonance imaging as a marker of neuronal activity. Our hypothesis was that increased LFP in cerebral blood flow (CBF) would be correlated with improvements in invasive measures of neurologic health. MethodsWe adapted the use of LFP for to monitoring of CBF with diffuse correlation spectroscopy. We asked whether LFP (or other optical biomarkers) correlated with invasive microdialysis biomarkers (lactate-pyruvate ratio – LPR – and glycerol concentration) of neuronal injury in the 4 h after return of spontaneous circulation in a swine model of paediatric cardiac arrest (Sus scrofa domestica, 8–11 kg, 51% female). Associations were tested using a mixed linear effects model. ResultsWe found that higher LFP was associated with higher LPR and higher glycerol concentration. No other biomarkers were associated with LPR; cerebral haemoglobin concentration, oxygen extraction fraction, and one EEG metric were associated with glycerol concentration. ConclusionContrary to expectations, higher LFP in CBF was correlated with worse invasive biomarkers. Higher LFP may represent higher neurologic activity, or disruptions in neurovascular coupling. Either effect may be harmful in the acute period after cardiac arrest. Thus, these results suggest our methodology holds promise for development of new, clinically relevant biomarkers than can guide resuscitation and post-resuscitation care.Institutional protocol number: 19-001327.

Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study.

BackgroundKnowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates.MethodsWe performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes.ResultsA total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%). ConclusionsSurvival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.

Use of Magnetic Resonance Imaging in Neuroprognostication After Pediatric Cardiac Arrest: Survey of Current Practices

BackgroundUse of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA. MethodsA survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support. ResultsResponse rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers. ConclusionsConventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies.

Association of EEG and Blood-Based Brain Injury Biomarker Accuracy to Prognosticate Mortality After Pediatric Cardiac Arrest: An Exploratory Study

BackgroundEvaluate the accuracy of brain-based blood biomarkers neuron-specific enolase (NSE) and S100b and electroencephalography (EEG) features alone and in combination with prognosticate 6-month mortality after pediatric cardiac arrest. We hypothesized that the combination of blood brain-based biomarkers and EEG features would have superior classification accuracy of outcome versus either alone. MethodsChildren (n = 58) aged between 1 week and 17 years admitted to the ICU following cardiac arrest at a tertiary care children's hopital were eligible for this secondary study. Blood NSE and S100b were measured closest to 24 hours after return of spontaneous circulation (ROSC). EEGs closest to 24 hours (median 11, interquartile range [IQR] 6 to 16 h) post-ROSC were evaluated by two epileptologists. EEG grade was informed by background frequency, amplitude, and continuity. Sleep spindles were present or absent. Mortality was assessed at six months post-ROSC. Area under the receiver operator curve (AUC) was performed for individual and combined brain-based biomarkers and EEG features. ResultsChildren were aged 2.6 (IQR 0.6 to 10.4) years, and 25 (43%) died. Children who died had increased blood NSE (49.7 [28.0 to 63.1] vs 18.2 [9.8 to 31.8] ng/mL) and S100b (0.118 [0.036 to 0.296] vs 0.012 [0.003 to 0.021] ng/mL) and poor (discontinuous or isoelectric) EEG grade (76% vs 33%) more frequently than survivors (P < 0.05). AUC for NSE to predict mortality was 0.789, and was 0.841 when combined with EEG grade and spindles. S100b AUC for mortality was 0.856 and was optimal alone. ConclusionsIn this exploratory study, the combination of brain-based biomarkers and EEG features may provide more accurate prognostication than either test alone after pediatric cardiac arrest.