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Gathers CAL, McSherry ML, Topjian A. The Heart of the Matter: Untangling Difficult Choices after Pediatric Cardiac Arrest. Resuscitation 2024:110260. [PMID: 38844025 DOI: 10.1016/j.resuscitation.2024.110260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Cody-Aaron L Gathers
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Megan L McSherry
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis Topjian
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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2
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Ross CE. Oxygenation and Ventilation after Pediatric In-Hospital Cardiac Arrest: Moving Targets? Ann Am Thorac Soc 2024; 21:856-857. [PMID: 38819137 PMCID: PMC11160124 DOI: 10.1513/annalsats.202404-339ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- Catherine E Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, and
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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3
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Frazier AH, Topjian AA, Reeder RW, Morgan RW, Fink EL, Franzon D, Graham K, Harding ML, Mourani PM, Nadkarni VM, Wolfe HA, Ahmed T, Bell MJ, Burns C, Carcillo JA, Carpenter TC, Diddle JW, Federman M, Friess SH, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Meert KL, Naim MY, Notterman D, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Yates AR, Sutton RM, Berg RA. Association of Pediatric Postcardiac Arrest Ventilation and Oxygenation with Survival Outcomes. Ann Am Thorac Soc 2024; 21:895-906. [PMID: 38507645 PMCID: PMC11160133 DOI: 10.1513/annalsats.202311-948oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/18/2024] [Indexed: 03/22/2024] Open
Abstract
Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, compared with postarrest normoxemia, and whether postarrest hypocapnia or hypercapnia is associated with lower rates of survival, compared with postarrest normocapnia. Methods: An embedded prospective observational study during a multicenter interventional cardiopulmonary resuscitation trial was conducted from 2016 to 2021. Patients ⩽18 years old and with a corrected gestational age of ≥37 weeks who received chest compressions for cardiac arrest in one of the 18 intensive care units were included. Exposures during the first 24 hours postarrest were hypoxemia, hyperoxemia, or normoxemia-defined as lowest arterial oxygen tension/pressure (PaO2) <60 mm Hg, highest PaO2 ⩾200 mm Hg, or every PaO2 60-199 mm Hg, respectively-and hypocapnia, hypercapnia, or normocapnia, defined as lowest arterial carbon dioxide tension/pressure (PaCO2) <30 mm Hg, highest PaCO2 ⩾50 mm Hg, or every PaCO2 30-49 mm Hg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates. Results: The hypoxemia group was less likely to survive to hospital discharge, compared with the normoxemia group (adjusted relative risk [aRR] = 0.71; 95% confidence interval [CI] = 0.58-0.87), whereas survival in the hyperoxemia group did not differ from that in the normoxemia group (aRR = 1.0; 95% CI = 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge, compared with the normocapnia group (aRR = 0.74; 95% CI = 0.64-0.84), whereas survival in the hypocapnia group did not differ from that in the normocapnia group (aRR = 0.91; 95% CI = 0.74-1.12). Conclusions: Postarrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Aisha H. Frazier
- Nemours Cardiac Center, and
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ericka L. Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, California
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Peter M. Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Vinay M. Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather A. Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tageldin Ahmed
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Michael J. Bell
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C. Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - J. Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Stuart H. Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Mark Hall
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - David A. Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher M. Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L. Huard
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Maryam Y. Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Matthew P. Sharron
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, California
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R. Yates
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio; and
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Kadden M, Zhang A, Shoykhet M. Association of temperature management strategy with fever in critically ill children after out-of-hospital cardiac arrest. Front Pediatr 2024; 12:1355385. [PMID: 38659696 PMCID: PMC11039828 DOI: 10.3389/fped.2024.1355385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Objective To determine whether ICU temperature management strategy is associated with fever in children with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). Methods We conducted a single-center retrospective cohort study at a quaternary Children's hospital between 1/1/2016-31/12/2020. Mechanically ventilated children (<18 y/o) admitted to Pediatric or Cardiac ICU (PICU/CICU) with ROSC after OHCA who survived at least 72 h were included. Primary exposure was initial PICU/CICU temperature management strategy of: (1) passive management; or (2) warming with an air-warming blanket; or (3) targeted temperature management with a heating/cooling (homeothermic) blanket. Primary outcome was fever (≥38°C) within 72 h of admission. Results Over the study period, 111 children with ROSC after OHCA were admitted to PICU/CICU, received mechanical ventilation and survived at least 72 h. Median age was 31 (IQR 6-135) months, 64% (71/111) were male, and 49% (54/111) were previously healthy. Fever within 72 h of admission occurred in 51% (57/111) of patients. The choice of initial temperature management strategy was associated with occurrence of fever (χ2 = 9.36, df = 2, p = 0.009). Fever occurred in 60% (43/72) of patients managed passively, 45% (13/29) of patients managed with the air-warming blanket and 10% (1/10) of patients managed with the homeothermic blanket. Compared to passive management, use of homeothermic, but not of air-warming, blanket reduced fever risk [homeothermic: Risk Ratio (RR) = 0.17, 95%CI 0.03-0.69; air-warming: RR = 0.75, 95%CI 0.46-1.12]. To prevent fever in one child using a homeothermic blanket, number needed to treat (NNT) = 2. Conclusion In critically ill children with ROSC after OHCA, ICU temperature management strategy is associated with fever. Use of a heating/cooling blanket with homeothermic feedback reduces fever incidence during post-arrest care.
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Affiliation(s)
- Micah Kadden
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Pediatric Critical Care Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Anqing Zhang
- Division of Biostatistics and Study Methodology, Children’s National Hospital, Silver Spring, MD, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
| | - Michael Shoykhet
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
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Vassar R, Mehta N, Epps L, Jiang F, Amorim E, Wietstock S. Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study. Pediatr Crit Care Med 2024; 25:241-249. [PMID: 37982686 DOI: 10.1097/pcc.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Pediatric out-of-hospital cardiac arrest (OHCA) is associated with substantial morbidity and mortality. Limited data exist to guide timing and method of neurologic prognostication after pediatric OHCA, making counseling on withdrawal of life-sustaining therapies (WLSTs) challenging. This study investigates the timing and mode of death after pediatric OHCA and factors associated with mortality. Additionally, this study explores delayed recovery after comatose examination on day 3 postarrest. DESIGN This is a retrospective, observational study based on data collected from hospital databases and chart reviews. SETTING Data collection occurred in two pediatric academic hospitals between January 1, 2016, and December 31, 2020. PATIENTS Patients were identified from available databases and electronic medical record queries for the International Classification of Diseases , 10th Edition (ICD-10) code I46.9 (Cardiac Arrest). Patient inclusion criteria included age range greater than or equal to 48 hours to less than 18 years, OHCA within 24 hours of admission, greater than or equal to 1 min of cardiopulmonary resuscitation, and return-of-spontaneous circulation for greater than or equal to 20 min. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty-five children (65% male) with a median age of 3 years (interquartile range 0.6-11.8) met inclusion criteria. Overall, 63 of 135 patients (47%) died before hospital discharge, including 34 of 63 patients (54%) after WLST. Among these, 20 of 34 patients underwent WLST less than or equal to 3 days postarrest, including 10 of 34 patients who underwent WLST within 1 day. WLST occurred because of poor perceived neurologic prognosis in all cases, although 7 of 34 also had poor perceived systemic prognosis. Delayed neurologic recovery from coma on day 3 postarrest was observed in 7 of 72 children (10%) who ultimately survived to discharge. CONCLUSIONS In our two centers between 2016 and 2020, more than half the deaths after pediatric OHCA occurred after WLST, and a majority of WLST occurred within 3 days postarrest. Additional research is warranted to determine optimal timing and predictors of neurologic prognosis after pediatric OHCA to better inform families during goals of care discussions.
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Affiliation(s)
- Rachel Vassar
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Nehali Mehta
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lane Epps
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Fei Jiang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Division of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Sharon Wietstock
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital Oakland, University of California, San Francisco, Oakland, CA
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Hunfeld M, Dulfer K, Del Castillo J, Vázquez M, Buysse C. Long-term multidisciplinary follow-up programs in pediatric cardiac arrest survivors. Resusc Plus 2024; 17:100563. [PMID: 38328751 PMCID: PMC10847941 DOI: 10.1016/j.resplu.2024.100563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Long-term outcome studies after pediatric cardiac arrest (CA) are few. They require a CA registry and dedicated outcome teams. Learning about the long-term outcomes is very important for developing prognostication guidelines, improving post-cardiac care, counseling caregivers about the future of their child, and creating opportunities for therapeutic intervention studies to improve outcomes. Few PICUs worldwide provide a multidisciplinary follow-up program as routine practice at an outpatient clinic with standardized measurements, using validated instruments including neuropsychological assessments by psychologists. The primary goal of such a follow-up program should be to provide excellent care to children and their caregivers, thereby resulting in a high attendance. Pediatric psychologists, neurologists and pediatricians/pediatric intensivists should ideally be involved to screen for delayed development and psychosocial problems and offer appropriate care at the same time. Preferably, outcomes should consist of evaluation of morbidity (physical and neuropsychological), functional health and Health Related Quality Of Life (QoL) of the patient and their caregivers.
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Affiliation(s)
- M. Hunfeld
- Department of Neonatal and Pediatric Intensive Care Unit, Division of Pediatric Intensive Care Unit, Erasmus MC Children’s Hospital, Rotterdam, the Netherlands
| | - K. Dulfer
- Department of Neonatal and Pediatric Intensive Care Unit, Division of Pediatric Intensive Care Unit, Erasmus MC Children’s Hospital, Rotterdam, the Netherlands
| | - J. Del Castillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origen Network (RICORS-RD21/0012/0011), Spain
| | - M. Vázquez
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origen Network (RICORS-RD21/0012/0011), Spain
| | - C.M.P. Buysse
- Department of Neonatal and Pediatric Intensive Care Unit, Division of Pediatric Intensive Care Unit, Erasmus MC Children’s Hospital, Rotterdam, the Netherlands
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Circulation 2023; 148:e120-e146. [PMID: 37551611 DOI: 10.1161/cir.0000000000001125] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Morrison LJ, Sandroni C, Grunau B, Parr M, Macneil F, Perkins GD, Aibiki M, Censullo E, Lin S, Neumar RW, Brooks SC. Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2023; 190:109864. [PMID: 37548950 DOI: 10.1016/j.resuscitation.2023.109864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
AIM OF THE REVIEW Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries. METHODS The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section. RESULTS There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness. CONCLUSIONS All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.
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Hunfeld M, Buysse CMP. Long-term outcome in pediatric cardiac arrest survivors: not without a neuro-prognostication guideline and structured follow-up until young adulthood. Resuscitation 2023; 187:109802. [PMID: 37088273 DOI: 10.1016/j.resuscitation.2023.109802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Affiliation(s)
- Maayke Hunfeld
- Department of Neonatal and Pediatric Intensive Care Unit, Division of Pediatric Intensive Care Unit, Erasmus MC Children's Hospital, Rotterdam, the Netherlands
| | - Corinne M P Buysse
- Department of Neonatal and Pediatric Intensive Care Unit, Division of Pediatric Intensive Care Unit, Erasmus MC Children's Hospital, Rotterdam, the Netherlands.
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10
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Henry M, Filipp SL, Aydin EY, Chiriboga N, Zelinka K, Smith LE, Gurka MJ, Irazuzta J, Fonseca Y, Winter MC, Pringle C. Multicentric validation of a prognostic tool for predicting brain death following out-of-hospital cardiac arrest in children. Resuscitation 2023; 185:109727. [PMID: 36764571 PMCID: PMC10065949 DOI: 10.1016/j.resuscitation.2023.109727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
AIM Out-of-hospital cardiac arrest (OHCA) in pediatric patients is associated with high rates of mortality and neurologic injury, with no definitive evidence-based method to predict outcomes available. A prognostic scoring tool for adults, The Brain Death After Cardiac Arrest (BDCA) score, was recently developed and validated. We aimed to validate this score in pediatric patients. METHODS Retrospective cohort study of pediatric patients admitted to 5 PICUs after OHCA between 2011 and 2021. We extracted BDCA score elements for those who survived at least 24 hours but died as a result of their OHCA. We assessed score discrimination for the definitive outcome of brain death. Subgroup analysis was performed for infants < 12mo versus children ≥ 12mo, those who likely had brain death but had withdrawal of life sustaining therapy (WLST) prior to declaration, and by etiology and duration of arrest. RESULTS 389 subjects were identified across 5 institutions, with 282 meeting inclusion criteria. 169 (59.9%) were formally declared brain dead; 58 (20.6%) had findings consistent with brain death but had withdrawal of life sustaining therapies prior to completion of formal declaration. Area under the receiver operating characteristic curve for the age ≥ 12mo cohort was 0.82 [95% CI 0.75, 0.90], which mirrored the adult subject AUCs of 0.82 [0.77, 0.86] and 0.81 [0.76, 0.86] in the development and validation cohorts. Scores demonstrated worse discrimination in the infant cohort (AUC = 0.61). CONCLUSIONS The BDCA score shows promise in children ≥ 12mo following OHCA and may be considered in conjunction with existing multimodal prognostication approaches.
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Affiliation(s)
- Matthew Henry
- College of Medicine, Department of Pediatrics, Critical Care Medicine, University of Florida, PO Box 100296, Gainesville, FL 32610, United States.
| | - Stephanie L Filipp
- College of Medicine, Department of Pediatrics, Pediatric Research Hub, University of Florida, United States
| | - Elber Yuksel Aydin
- College of Medicine, Department of Pediatrics, Critical Care Medicine, University of Florida-Jacksonville, United States
| | - Nicolas Chiriboga
- Pediatric Neurocritical Care, Northwestern University Feinberg School of Medicine, United States
| | - Kailea Zelinka
- Department of Pediatrics, Critical Care Medicine, University of Maryland, United States
| | - Lorena Espinosa Smith
- Children's Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, United States
| | - Matthew J Gurka
- College of Medicine, Department of Pediatrics, Pediatric Research Hub, University of Florida, United States
| | - Jose Irazuzta
- College of Medicine, Department of Pediatrics, Critical Care Medicine, University of Florida-Jacksonville, United States
| | - Yudy Fonseca
- Department of Pediatrics, Critical Care Medicine, University of Maryland School of Medicine, United States
| | - Meredith C Winter
- Children's Hospital Los Angeles, Department of Anesthesiology Critical Care Medicine, United States; University of Southern California Keck School of Medicine, Department of Pediatrics, United States
| | - Charlene Pringle
- College of Medicine, Department of Pediatrics, Critical Care Medicine, University of Florida, PO Box 100296, Gainesville, FL 32610, United States
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11
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Kochanek PM, Simon DW, Wagner AK. Targeting interleukin-6 after cardiac arrest-Let us not forget the brain. Resuscitation 2023; 184:109715. [PMID: 36736948 DOI: 10.1016/j.resuscitation.2023.109715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Patrick M Kochanek
- Critical Care Medicine, Anesthesiology, Pediatrics, and Clinical and Translational Science, Safar Center for Resuscitation Research, UPMC Children's Hospital of Pittsburgh, Rangos Research Center - 6th floor, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Dennis W Simon
- Departments of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, Children's Neuroscience Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, United States.
| | - Amy K Wagner
- Neuroscience, Departments of Physical Medicine & Rehabilitation and Neuroscience, Center for Neuroscience, Safar Center for Resuscitation Research, Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Suite 202, Pittsburgh, PA 15261, United States.
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Wittwer MR, Armstrong T, Conway J, Ruknuddeen MI, Zeitz C, Beltrame JF, Arstall MA. In-hospital mode of death after out-of-hospital cardiac arrest. Resusc Plus 2022; 10:100229. [PMID: 35368521 PMCID: PMC8971337 DOI: 10.1016/j.resplu.2022.100229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 01/27/2023] Open
Abstract
Introduction Factors associated with in-hospital mortality after out-of-hospital cardiac arrest (OHCA), such as mode of death and withdrawal of life-sustaining treatment (WLST), are not well established. This study aimed to compare clinical characteristics, timing of WLST and death, and precipitating aetiology between modes of death for OHCAs treated at hospital within a local health network. Methods Retrospective cohort study of adult non-traumatic OHCAs included in a hospital based OHCA registry between 2011 and 2016 and deceased at hospital discharge, excluding cases retrieved to external hospitals. Mode of death was defined as (1) cardiovascular instability, (2) non-neurological WLST, (3) neurological WLST, and (4) formal brain death. Relevant data were extracted from the registry and stratified according to mode of death and timing of death as early (within the emergency department) or late (after admission). Results Mode of death data was available for 69 early and 144 late deaths. Cardiovascular instability was the primary mode for 75% of early deaths, while 72% of late deaths were attributed to neurological injury (47% neurological WLST and 24% brain death, combined). Cardiovascular instability was associated with cardiac aetiology, brain death was associated with younger age and highest rates of organ donation, and neurological WLST was associated with highest rates of targeted temperature management, and longest time from arrest to death (p < 0.05). Conclusions This is the first study to compare clinical characteristics of adult patients resuscitated from OHCA according to in-hospital mode of death. A consensus on the definition of mode of death with standardised classification is needed.
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Affiliation(s)
- Melanie R Wittwer
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia
- Corresponding author at: Department of Cardiology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112, Australia.
| | - Thomas Armstrong
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jordan Conway
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Mohammed Ishaq Ruknuddeen
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia
| | - Chris Zeitz
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - John F Beltrame
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Margaret A Arstall
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Elizabeth Vale, South Australia, Australia
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13
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Harris M, Crowe RP, Anders J, D'Acunto S, Adelgais KM, Fishe JN. Identification of factors associated with return of spontaneous circulation after pediatric out-of-hospital cardiac arrest using natural language processing. PREHOSP EMERG CARE 2022:1-8. [PMID: 35510881 DOI: 10.1080/10903127.2022.2074180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Introduction: Prior studies examining prehospital characteristics related to return of spontaneous circulation (ROSC) in pediatric out-of-hospital cardiac arrest (OHCA) are limited to structured data. Natural language processing (NLP) could identify new factors from unstructured data using free-text narratives. The purpose of this study was to use NLP to examine EMS clinician free-text narratives for characteristics associated with prehospital ROSC in pediatric OHCA.Methods: This was a retrospective analysis of patients ages 0-17 with OHCA in 2019 from the ESO Data Collaborative. We performed an exploratory analysis of EMS narratives using NLP with an a priori token library. We then constructed biostatistical and machine learning models and compared their performance in predicting ROSC.Results: There were 1,726 included EMS encounters for pediatric OHCA; 60% were male patients, and the median age was 1 year (IQR 0-9). Most cardiac arrest events (61.3%) were unwitnessed, 87.3% were identified as having medical causes, and 5.9% had initial shockable rhythms. Prehospital ROSC was achieved in 23.1%. Words most positively correlated with ROSC were "ROSC" (r = 0.42), "pulse" (r = 0.29), "drowning" (r = 0.13), and "PEA" (r = 0.12). Words negatively correlated with ROSC included "asystole" (r = -0.25), "lividity" (r = -0.14), and "cold" (r = -0.14). The terms 'asystole,' 'pulse', 'no breathing', 'PEA', and 'dry' had the greatest difference in frequency of appearance between encounters with and without ROSC (p < 0.05). The best-performing model for predicting prehospital ROSC was logistic regression with random oversampling using free-text data only (area under the receiver operating characteristic curve 0.92).Conclusions: EMS clinician free-text narratives reveal additional characteristics associated with prehospital ROSC in pediatric OHCA. Incorporating those terms into machine learning models of prehospital ROSC improves predictive ability. Therefore, NLP holds promise as a tool for use in predictive models with the goal to increase evidence-based management of pediatric OHCA.
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Affiliation(s)
- Matthew Harris
- Northwell Hofstra School of Medicine, Departments of Pediatrics and Emergency Medicine, New Hyde Park, NY
| | | | - Jennifer Anders
- Johns Hopkins School of Medicine, Department of Pediatrics, Baltimore, MD
| | - Salvatore D'Acunto
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL
| | - Kathlen M Adelgais
- University of Colorado School of Medicine, Department of Pediatrics, Section of Pediatric Emergency Medicine, Aurora, CO
| | - Jennifer N Fishe
- University of Florida College of Medicine - Jacksonville, Center for Data Solutions, Jacksonville, FL.,University of Florida College of Medicine - Jacksonville, Department of Emergency Medicine, Jacksonville, FL
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14
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Multimodal monitoring including early EEG improves stratification of brain injury severity after pediatric cardiac arrest. Resuscitation 2021; 167:282-288. [PMID: 34237356 DOI: 10.1016/j.resuscitation.2021.06.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/11/2021] [Accepted: 06/20/2021] [Indexed: 12/14/2022]
Abstract
AIMS Assessment of brain injury severity early after cardiac arrest (CA) may guide therapeutic interventions and help clinicians counsel families regarding neurologic prognosis. We aimed to determine whether adding EEG features to predictive models including clinical variables and examination signs increased the accuracy of short-term neurobehavioral outcome prediction. METHODS This was a prospective, observational, single-center study of consecutive infants and children resuscitated from CA. Standardized EEG scoring was performed by an electroencephalographer for the initial EEG timepoint after return of spontaneous circulation (ROSC) and each 12-h segment from the time of ROSC up to 48 h. EEG Background Category was scored as: (1) normal; (2) slow-disorganized; (3) discontinuous or burst-suppression; or (4) attenuated-featureless. The primary outcome was neurobehavioral outcome at discharge from the Pediatric Intensive Care Unit. To develop the final predictive model, we compared areas under the receiver operating characteristic curves (AUROC) from models with varying combinations of Demographic/Arrest Variables, Examination Signs, and EEG Features. RESULTS We evaluated 89 infants and children. Initial EEG Background Category was normal in 9 subjects (10%), slow-disorganized in 44 (49%), discontinuous or burst suppression in 22 (25%), and attenuated-featureless in 14 (16%). The final model included Demographic/Arrest Variables (witnessed status, doses of epinephrine, initial lactate after ROSC) and EEG Background Category which achieved AUROC of 0.9 for unfavorable neurobehavioral outcome and 0.83 for mortality. CONCLUSIONS The addition of standardized EEG Background Categories to readily available CA variables significantly improved early stratification of brain injury severity after pediatric CA.
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15
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Morgan RW, Kirschen MP, Kilbaugh TJ, Sutton RM, Topjian AA. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr 2021; 175:293-302. [PMID: 33226408 PMCID: PMC8787313 DOI: 10.1001/jamapediatrics.2020.5039] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR). OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes. CONCLUSIONS AND RELEVANCE Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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16
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Butt W, Butlinski A. Out-of-Hospital Cardiac Arrest-Is International Agreement on Guidelines for Limits of Treatment Possible? Pediatr Crit Care Med 2021; 22:130-132. [PMID: 33410647 DOI: 10.1097/pcc.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Warwick Butt
- Intensive Care Unit, Royal Childrens Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Central Medical School, Monash University, Melbourne, VIC, Australia.,Clinical Sciences Theme, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Anna Butlinski
- Intensive Care Unit, Royal Childrens Hospital, Melbourne, VIC, Australia.,Clinical Sciences Theme, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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Hunfeld M, Nadkarni VM, Topjian A, Harpman J, Tibboel D, van Rosmalen J, de Hoog M, Catsman-Berrevoets CE, Buysse CMP. Timing and Cause of Death in Children Following Return of Circulation After Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2021; 22:101-113. [PMID: 33027241 DOI: 10.1097/pcc.0000000000002577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine timing and cause of death in children admitted to the PICU following return of circulation after out-of-hospital cardiac arrest. DESIGN Retrospective observational study. SETTING Single-center observational cohort study at the PICU of a tertiary-care hospital (Erasmus MC-Sophia, Rotterdam, The Netherlands) between 2012 and 2017. PATIENTS Children younger than 18 years old with out-of-hospital cardiac arrest and return of circulation admitted to the PICU. MEASUREMENTS AND RESULTS Data included general, cardiopulmonary resuscitation and postreturn of circulation characteristics. The primary outcome was defined as survival to hospital discharge. Modes of death were classified as brain death, withdrawal of life-sustaining therapies due to poor neurologic prognosis, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure, and recurrent cardiac arrest without return of circulation. One hundred thirteen children with out-of-hospital cardiac arrest were admitted to the PICU following return of circulation (median age 53 months, 64% male, most common cause of out-of-hospital cardiac arrest drowning [21%]). In these 113 children, there was 44% survival to hospital discharge and 56% nonsurvival to hospital discharge (brain death 29%, withdrawal of life-sustaining therapies due to poor neurologic prognosis 67%, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure 2%, and recurrent cardiac arrest 2%). Compared with nonsurvivors, more survivors had witnessed arrest (p = 0.007), initial shockable rhythm (p < 0.001), shorter cardiopulmonary resuscitation duration (p < 0.001), and more favorable clinical neurologic examination within 24 hours after admission. Basic cardiopulmonary resuscitation event and postreturn of circulation (except for the number of extracorporeal membrane oxygenation) characteristics did not significantly differ between the withdrawal of life-sustaining therapies due to poor neurologic prognosis and brain death patients. Timing of decision-making to withdrawal of life-sustaining therapies due to poor neurologic prognosis ranged from 0 to 18 days (median: 0 d; interquartile range, 0-3) after cardiopulmonary resuscitation. The decision to withdrawal of life-sustaining therapies was based on neurologic examination (100%), electroencephalography (44%), and/or brain imaging (35%). CONCLUSIONS More than half of children who achieve return of circulation after out-of-hospital cardiac arrest died after PICU admission. Of these deaths, two thirds (67%) underwent withdrawal of life-sustaining therapies based on an expected poor neurologic prognosis and did so early after return of circulation. There is a need for international guidelines for accurate neuroprognostication in children after cardiac arrest.
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Affiliation(s)
- Maayke Hunfeld
- Department of Pediatric Neurology, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jasmijn Harpman
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Matthijs de Hoog
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Corinne M P Buysse
- Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
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18
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Kirschen MP, Licht DJ, Faerber J, Mondal A, Graham K, Winters M, Balu R, Diaz-Arrastia R, Berg RA, Topjian A, Vossough A. Association of MRI Brain Injury With Outcome After Pediatric Out-of-Hospital Cardiac Arrest. Neurology 2020; 96:e719-e731. [PMID: 33208547 DOI: 10.1212/wnl.0000000000011217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To determine the association between the extent of diffusion restriction and T2/fluid-attenuated inversion recovery (FLAIR) injury on brain MRI and outcomes after pediatric out-of-hospital cardiac arrest (OHCA). METHODS Diffusion restriction and T2/FLAIR injury were described according to the pediatric MRI modification of the Alberta Stroke Program Early Computed Tomography Score (modsASPECTS) for children from 2005 to 2013 who had an MRI within 14 days of OHCA. The primary outcome was unfavorable neurologic outcome defined as ≥1 change in Pediatric Cerebral Performance Category (PCPC) from baseline resulting in a hospital discharge PCPC score 3, 4, 5, or 6. Patients with unfavorable outcomes were further categorized into alive with PCPC 3-5, dead due to withdrawal of life-sustaining therapies for poor neurologic prognosis (WLST-neuro), or dead by neurologic criteria. RESULTS We evaluated MRI scans from 77 patients (median age 2.21 [interquartile range 0.44, 13.07] years) performed 4 (2, 6) days postarrest. Patients with unfavorable outcomes had more extensive diffusion restriction (median 7 [4, 10.3] vs 0 [0, 0] regions, p < 0.001) and T2/FLAIR injury (5.5 [2.3, 8.2] vs 0 [0, 0.75] regions, p < 0.001) compared to patients with favorable outcomes. Area under the receiver operating characteristic curve for the extent of diffusion restriction and unfavorable outcome was 0.96 (95% confidence interval [CI] 0.91, 0.99) and 0.92 (95% CI 0.85, 0.97) for T2/FLAIR injury. There was no difference in extent of diffusion restriction between patients who were alive with an unfavorable outcome and patients who died from WLST-neuro (p = 0.11). CONCLUSIONS More extensive diffusion restriction and T2/FLAIR injury on the modsASPECTS score within the first 14 days after pediatric cardiac arrest was associated with unfavorable outcomes at hospital discharge.
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Affiliation(s)
- Matthew P Kirschen
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
| | - Daniel J Licht
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jennifer Faerber
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Antara Mondal
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kathryn Graham
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Madeline Winters
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ramani Balu
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ramon Diaz-Arrastia
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert A Berg
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis Topjian
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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19
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The Prognostic Value of Early Amplitude-Integrated Electroencephalography Monitoring After Pediatric Cardiac Arrest. Pediatr Crit Care Med 2020; 21:248-255. [PMID: 31688714 DOI: 10.1097/pcc.0000000000002171] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess the ability of amplitude-integrated electroencephalography monitoring within 24 hours of the return of spontaneous circulation to prognosticate neurologic outcomes in children following cardiac arrest DESIGN:: Retrospective review of prospectively recorded data. An amplitude-integrated electroencephalography background score was calculated according to background activity during the first 24 hours after return of spontaneous circulation, a higher score correlating with more impaired background activity. The primary endpoint was the neurologic outcome as defined by the Pediatric Cerebral Performance Category at PICU discharge (Pediatric Cerebral Performance Category 1-3: a good neurologic outcome; Pediatric Cerebral Performance Category 4-6: a poor neurologic outcome). SETTING A referral PICU. PATIENTS Thirty children with a median age of 10 months (2-38 mo) and a male/female sex ratio of 1.3 were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighteen patients were assigned to the favorable outcome group and 12 to the unfavorable outcome group. The median time between return of spontaneous circulation and amplitude-integrated electroencephalography initiation was 4 hours (3-9 hr). The amplitude-integrated electroencephalography score within 24 hours after return of spontaneous circulation was significantly higher in the children with poor outcomes compared with those with good outcomes (12 ± 4 vs 25 ± 8; p < 0.001). Background activity during amplitude-integrated electroencephalography monitoring was able to predict poor neurologic outcomes at PICU discharge, with an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.81-1.00). CONCLUSIONS Early amplitude-integrated electroencephalography monitoring may help predict poor neurologic outcomes in children within 24 hours following cardiac arrest.
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20
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Laverriere EK, Polansky M, French B, Nadkarni VM, Berg RA, Topjian AA. Association of Duration of Hypotension With Survival After Pediatric Cardiac Arrest. Pediatr Crit Care Med 2020; 21:143-149. [PMID: 31568263 DOI: 10.1097/pcc.0000000000002119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the association of a single episode of hypotension and burden of hypotension with survival to hospital discharge following resuscitation from pediatric cardiac arrest. DESIGN Retrospective cohort study. SETTING Single-center PICU. PATIENTS Patients between 1 day and 18 years old who had a cardiac arrest, received chest compressions for more than 2 minutes, had return of spontaneous circulation for more than 20 minutes, and survived to receive postresuscitation care in the ICU. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS One-hundred sixteen patients were evaluable. Hypotension, defined as systolic blood pressure less than the fifth percentile for age and sex, occurred in 37 patients (32%) within the first 6 hours and 64 (55%) within 72 hours of postresuscitation ICU care. There was no significant difference in survival to discharge for patients who had a single episode of hypotension within 6 hours (51% vs 69%; p = 0.06) or within 72 hours (56% vs 73%; p = 0.06). Burden of hypotension was defined as the percentage of hypotension measurements that were below the fifth percentile. After controlling for patient and cardiac arrest event characteristics, a higher burden of hypotension within the first 72 hours of ICU postresuscitation care was associated with decreased discharge survival (adjusted odds ratio = 0.67 per 10% increase in hypotension burden; 95% CI, 0.48-0.86; p = 0.006). CONCLUSIONS After successful resuscitation from pediatric cardiac arrest, systolic hypotension was common (55%). A higher burden of postresuscitation hypotension within the first 72 hours of ICU postresuscitation care was associated with significantly decreased discharge survival, after accounting for potential confounders including number of doses of epinephrine, arrest location, and arrest etiology due to airway obstruction or trauma.
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Affiliation(s)
- Elizabeth K Laverriere
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Marcia Polansky
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Robert A Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Alexis A Topjian
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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21
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Abstract
PURPOSE We aimed to determine which early EEG features and feature combinations most accurately predicted short-term neurobehavioral outcomes and survival in children resuscitated after cardiac arrest. METHODS This was a prospective, single-center observational study of infants and children resuscitated from cardiac arrest who underwent conventional EEG monitoring with standardized EEG scoring. Logistic regression evaluated the marginal effect of each EEG variable or EEG variable combinations on the outcome. The primary outcome was neurobehavioral outcome (Pediatric Cerebral Performance Category score), and the secondary outcome was mortality. The authors identified the models with the highest areas under the receiver operating characteristic curve (AUC), evaluated the optimal models using a 5-fold cross-validation approach, and calculated test characteristics maximizing specificity. RESULTS Eighty-nine infants and children were evaluated. Unfavorable neurologic outcome (Pediatric Cerebral Performance Category score 4-6) occurred in 44 subjects (49%), including mortality in 30 subjects (34%). A model incorporating a four-level EEG Background Category (normal, slow-disorganized, discontinuous or burst-suppression, or attenuated-flat), stage 2 Sleep Transients (present or absent), and Reactivity-Variability (present or absent) had the highest AUC. Five-fold cross-validation for the optimal model predicting neurologic outcome indicated a mean AUC of 0.75 (range, 0.70-0.81) and for the optimal model predicting mortality indicated a mean AUC of 0.84 (range, 0.76-0.97). The specificity for unfavorable neurologic outcome and mortality were 95% and 97%, respectively. The positive predictive value for unfavorable neurologic outcome and mortality were both 86%. CONCLUSIONS The specificity of the optimal model using a combination of early EEG features was high for unfavorable neurologic outcome and mortality in critically ill children after cardiac arrest. However, the positive predictive value was only 86% for both outcomes. Therefore, EEG data must be considered in overall clinical context when used for neuroprognostication early after cardiac arrest.
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Knaup E, Nosaka N, Yorifuji T, Tsukahara K, Naito H, Tsukahara H, Nakao A. Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score. J Intensive Care 2019; 7:38. [PMID: 31384469 PMCID: PMC6664501 DOI: 10.1186/s40560-019-0392-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022] Open
Abstract
Background The length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission. Methods We performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017. Results Overall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%). Conclusions Pediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission. Electronic supplementary material The online version of this article (10.1186/s40560-019-0392-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily Knaup
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Nobuyuki Nosaka
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,3Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Takashi Yorifuji
- 4Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University, Okayama, Japan
| | - Kohei Tsukahara
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hiromichi Naito
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hirokazu Tsukahara
- 2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Atsunori Nakao
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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