Multicenter cohort study of out-of-hospital pediatric cardiac arrest

Sociodemographic disparities in incidence and survival for pediatric out-of-hospital cardiac arrest in the United States

BACKGROUND

Sociodemographic disparities in pediatric out-of-hospital cardiac arrest (OHCA) outcomes exist; differences in pediatric OHCA incidence remain unknown. This study investigated the association between race, ethnicity, and socioeconomic status (SES) with pediatric OHCA incidence and survival. We hypothesized that children who are Black, Hispanic/Latino, or of lower SES would have higher incidence and lower survival rates compared to children who are White or of higher SES.

METHODS

This is a retrospective cohort study (2015-2019) of the Cardiac Arrest Registry to Enhance Survival database. We included OHCAs among children < 18 years. The exposures were race, ethnicity, or SES index score. The SES index score incorporated race or ethnicity, household income, high school graduation rates, and unemployment rates on a scale from 0 to 4, with 4 indicating the highest-risk neighborhoods. The primary outcome was incidence (measured per 100,000 children of a particular group). Secondary outcomes included survival to hospital discharge and survival with a favorable neurologic outcome.

RESULTS

Among 6945 OHCAs, 2320 (33.4%) occurred in Black children, 739 (10.6%) in Hispanic/Latino children, 2161 (31.1%) in White children, 188 (2.7%) in children of Other race, and 2855 (41.2%) in highest-risk neighborhoods. Black children had the highest OHCA incidence (15.5) as compared to Hispanic/Latino children (3.3) and White children (3.8), p < 0.001. OHCA incidence was higher in highest-risk neighborhoods (11.6) compared to lowest-risk neighborhoods (4.3), p < 0.001. Black children had lower odds of survival to hospital discharge (adjusted odds ratio [aOR] 0.73, 95% CI 0.59-0.91) and neurologically favorable survival (aOR 0.64, 95% CI 0.50-0.82) compared to White children. Hispanic/Latino children did not have significantly worse survival outcomes compared to White children. Children from the highest-risk neighborhoods had lower odds of survival to hospital discharge (aOR 0.64, 95% CI 0.50-0.81) and neurologically favorable survival (aOR 0.54, 95% CI 0.41-0.71) compared to children from the lowest-risk neighborhoods.

CONCLUSIONS

Black children have over four times the OHCA incidence compared to White and Hispanic/Latino children. Children from the highest-risk neighborhoods have more than twice the OHCA incidence compared to children from the lowest-risk neighborhoods. Black children and children from the highest-risk neighborhoods have significantly lower OHCA survival rates.

Characteristics, Outcomes and Mortality Risk Factors of Pediatric In-Hospital Cardiac Arrest in Western China: A Retrospective Study Using Utstein Style

Background: Pediatric in-hospital cardiac arrest (IHCA) remains a critical health challenge with high mortality rates. Limited data from Western China prompted this study to investigate the characteristics of IHCA using the Utstein style. Methods: A retrospective analysis of 456 pediatric patients with IHCA (2018-2022) at the Children's Hospital of Chongqing Medical University assessed demographics, arrest characteristics, outcomes and mortality risk factors. The primary outcome was survival to discharge; the secondary outcomes included return of spontaneous circulation (ROSC) > 20 min, 24 h survival, and favorable neurological outcomes. Logistic regression was used to identify the mortality risk factors. Results: ROSC > 20 min was achieved in 78.07% of cases, with 37.94% surviving to discharge (86.13% of survivors had favorable neurological outcomes). Etiological stratification identified general medical conditions (52.63%) as the predominant diagnoses, with surgical cardiac patients demonstrating superior resuscitation outcomes (ROSC > 20 min: 86.84%, discharge survival: 64.04%). Initial arrest rhythms predominantly featured non-shockable patterns, specifically bradycardia with poor perfusion (79.39%), whereas shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia) constituted only 4.17% of cases. Multivariable regression analysis identified five independent risk factors: vasoactive infusion before arrest (OR = 7.69), CPR > 35 min (OR = 13.92), emergency intubation (OR = 5.17), administration of >2 epinephrine doses (OR = 3.12), and rearrest (OR = 8.48). Notably, prolonged CPR (>35 min) correlated with higher mortality (8.96% survival vs. 48.54% for 1-15 min), yet all six survivors with CPR > 35 min had favorable neurological outcomes. Conclusions: These findings underscore the persistent challenges in pediatric IHCA management while challenging the conventional CPR duration thresholds for futility. The identified mortality risk factors inform resuscitation decision making and future studies.

Prognostic Value of Brain Magnetic Resonance Imaging in Children After Out-of-Hospital Cardiac Arrest: Predictive Value of Normal Magnetic Resonance Imaging for a Favorable Two-Year Outcome

BACKGROUND

Determine the predictive value of brain magnetic resonance imaging (MRI) findings less than or equal to seven days post-pediatric out-of-hospital cardiac arrest (OHCA) for long-term outcomes.

METHODS

This retrospective single-center study included children (zero to 17 years) with OHCA admitted to a tertiary care hospital pediatrc intensive care unit from 2012 to 2020 who underwent brain MRI at most seven days postarrest. A neuroimaging scoring system was designed, using T1-, T2-, and diffusion-weighted images based on previously published scores and brain injury patterns. Extensive brain injury was defined as ≥50% cortex/white matter injury or four or more of nine predefined brain regions. Pediatric cerebral performance category (PCPC) scores were determined at hospital discharge and two years post-OHCA as part of routine follow-up care. Favorable neurological outcomes were defined as PCPC scores of 1 to 2 or no change from prearrest status.

RESULTS

Among 142 children, 56 had a brain MRI at less than or equal to seven days postarrest. Median arrest age was 3.3 years (first and third quartiles [Q1, Q3]: 0.6, 13.6), and 64% were male. Brain MRI was obtained four days post-OHCA (Q1, Q3: 3, 5). Normal brain MRI findings (i.e., negative test result) predicted favorable outcomes with 100% negative predictive value, whereas extensive injury (i.e., positive test result) predicted unfavorable outcomes and death with 100% positive predictive value.

CONCLUSIONS

A normal brain MRI at less than or equal to seven days postarrest predicts favorable neurological outcomes two years later, whereas extensive brain injury predicts unfavorable neurological outcomes or death at discharge and two years post-OHCA.

Automated external defibrillator: Rhythm analysis and defibrillation on paediatric out-of-hospital cardiac arrest

Objective

This study aims to quantify the reliability of automated external defibrillators (AED) in paediatric out-of-hospital cardiac arrests (pOHCA) by evaluating the defibrillation and the shock advisory system efficacy. Furthermore, the relationship between the initial energy dose and patient outcomes is analysed.

Methods

We studied data from all pOHCA cases (age < 18 years) treated by the Paris Fire Brigade between January 2010 and December 2018, limited to those with available AED signals. The efficacy of shocks is the primary outcome. The secondary outcomes are the shock advisory system performance, pre-hospital return of a spontaneous circulation (ROSC), survival and energy dose. Energy dose, weight and age are compared using a Wilcoxon test according to the outcome's values.

Results

A total of 1,990 electrocardiogram strips extracted from 349 pOHCA cases were included in the study. Shock advisory system had a sensitivity of 89.4% and a specificity of 99.8% for the detection of shockable rhythms. Shock efficacy observed for all patients who received a shock was 83.1% and first shock efficacy for patients in initial ventricular fibrillation was 96%. Patients who received a shock had a pre-hospital ROSC rate of 74.3%, a survival rate at hospital admission of 71.4% and 34.3% at hospital discharge.

Conclusion

This study shows that AED detect shockable rhythm with a good sensitivity and specificity and that shocks are associated with a very high rates of termination of shockable rhythms in pOHCA.

Social determinants of health and their associations with outcomes in pediatric out-of-hospital cardiac arrest: A national study of the NEMSIS database

Background

Social determinants of health (SDOH) impact health disparities, though little is known about the effects of SDOH on pediatric out-of-hospital cardiac arrest (POHCA).

Methods

This cross-sectional study utilized the NEMSIS Database to obtain nationwide POHCA data from 2021 to 2023. Outcomes included performance of bystander cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) usage, and obtainment of return of spontaneous circulation (ROSC). SDOH data was obtained from the US Census Bureau and included minority race/ethnicities status, poverty levels, and educational attainment of the community where POCHAs occurred. Multivariable logistic regression and Cochran-Armitage trend tests were used to assess associations between SDOH and POHCA outcomes.

Results

Query of the NEMSIS Database yielded 27,137 POHCAs. The odds of CPR performance and obtainment of ROSC were significantly higher (p < 0.001) in communities with lower levels of minority races/ethnicities. The odds of bystander CPR, AED usage, and obtainment of ROSC all increased significantly (p < 0.001) in the wealthiest communities compared to the poorest communities. The odds of bystander AED usage (p = 0.001) and ROSC (p = 0.003) were significantly higher in communities with the highest educational attainment. As the minority status and poverty level of the community increased and educational attainment decreased, there was a significant decreasing trend (p < 0.001) in performance of bystander CPR, AED usage, and obtainment of ROSC.

Conclusions

Community-level SDOH, including increasing community minority status, poverty levels, and decreasing educational attainment, are associated with less bystander CPR, AED usage, and ROSC obtainment in POHCAs. Understanding SDOH offers opportunities for public health interventions addressing disparities in POHCA outcomes.

Association between glycemia and outcomes of neonates with hypoxic-ischemic encephalopathy: a systematic review and meta-analysis

OBJECTIVES

The research aimed to provide the most recent and comprehensive analysis and evidence update comparing outcomes in neonatal encephalopathy (NE) based on different glycemia levels.

PATIENTS AND METHODS

A comprehensive search of Cochrane, PubMed, Embase, Web of Science, CNKI, and Wanfang databases was conducted until September 2023. The purpose was to identify research that examined the effects of hyperglycemia, hypoglycemia, and normoglycemia on NE outcomes. The hyperglycemic, normoglycemic and hypoglycemic group were compared. Outcomes measured were mortality, abnormal MRI, hearing or visual unfavorable outcomes, neurodevelopmental delay, cerebral palsy, and all unfavorable outcomes.

RESULTS

Thirteen literatures comprising 2,427 participants (1,233 with normoglycemia, 835 with hyperglycemia, and 359 with hypoglycemia) were considered. Pooled analysis showed more overall adverse outcomes, higher mortality and worse hearing or visual outcomes in the hyperglycemic and hypoglycemic group compared to the normoglycemic group. There was no notable distinction found in abnormal MRI and cerebral palsy among all groups. The hypoglycemic group exhibited greater neurodevelopmental delay than normoglycemia.

CONCLUSIONS

Maintaining normal blood glucose levels in neonates with NE can help reduce the risk of adverse consequences such as hearing and visual impairment.

Factors associated with family decision-making after pediatric out-of-hospital cardiac arrest

AIM

This study aims to identify demographic factors, area-based social determinants of health (SDOH), and clinical features associated with medical decision-making after pediatric out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective, exploratory, descriptive analysis of patients < 18 years old admitted to the pediatric intensive care unit (ICU) after OHCA from 2011 to 2022 (n = 217) at an urban tertiary care, free-standing children's hospital. Outcomes of interest included: (1) whether a new advance care plan (ACP) (defined as a written advance directive including do not resuscitate and/or do not intubate) was ordered during hospitalization, and (2) whether the patient was discharged with new medical technology (defined as tracheostomy and/or feeding tube). Logistic regression models identified features associated with these outcomes.

RESULTS

Of the 217 patients, 78 patients (36%) had a new ACP placed during their admission. Of the survivors, 26% (27/102) were discharged home with new medical technology. Factors associated with ACP were greater change in Pediatric Cerebral Performance Category (PCPC) score (aOR = 1.49, 95% CI [1.28-1.73], p-value < 0.001) and palliative care consultation (aOR = 2.39, 95% CI [1.16-4.89], p-value 0.018). Factors associated with new medical technology were lower change in PCPC score (aOR = 0.76, 95% C.I. [0.61-0.95], p-value = 0.015) and palliative care consultation (aOR = 7.07, 95% CI [3.01-16.60], p-value < 0.001). There were no associations between area-based SDOH and outcomes.

CONCLUSIONS

Understanding factors associated with decision-making related to ACP after OHCA is critical to optimize counseling for families. Multi-institutional studies are warranted to identify whether these findings are generalizable.

2024 RECOVER Guidelines: Advanced Life Support. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review the evidence and devise clinical recommendations on advanced life support (ALS) in dogs and cats and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to ALS following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by ALS Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Seventeen questions pertaining to vascular access, vasopressors in shockable and nonshockable rhythms, anticholinergics, defibrillation, antiarrhythmics, and adjunct drug therapy as well as open-chest CPR were reviewed. Of the 33 treatment recommendations formulated, 6 recommendations addressed the management of patients with nonshockable arrest rhythms, 10 addressed shockable rhythms, and 6 provided guidance on open-chest CPR. We recommend against high-dose epinephrine even after prolonged CPR and suggest that atropine, when indicated, is used only once. In animals with a shockable rhythm in which initial defibrillation was unsuccessful, we recommend doubling the defibrillator dose once and suggest vasopressin (or epinephrine if vasopressin is not available), esmolol, lidocaine in dogs, and/or amiodarone in cats.

CONCLUSIONS

These updated RECOVER ALS guidelines clarify the approach to refractory shockable rhythms and prolonged CPR. Very low quality of evidence due to absence of clinical data in dogs and cats continues to compromise the certainty with which recommendations can be made.

Association of temperature management strategy with fever in critically ill children after out-of-hospital cardiac arrest

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.

Survival and neurobehavioral outcomes following out-of-hospital cardiac arrest in pediatric patients with pre-existing morbidity: An analysis of the THAPCA out-of-hospital arrest data

AIM

Pre-arrest morbidity in adults who suffer out-of-hospital cardiac arrest (OHCA) is associated with increased mortality and poorer neurologic outcomes. The objective of this study was to determine if a similar association is seen in pediatric patients.

METHODS

We performed a secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Study sites included 36 pediatric intensive care units across the United States and Canada. The study enrolled children between the ages of 48 hours and 18 years following an OHCA between September 1, 2009 and December 31, 2012. For our analysis, patients with (N = 151) and without (N = 142) pre-arrest comorbidities were evaluated to assess morbidity, survival, and neurologic function following OHCA.

RESULTS

No significant difference in 28-day survival was seen between groups. Dependence on technology and neurobehavioral outcomes were assessed among survivors using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Children with pre-existing comorbidities maintained worse neurobehavioral function at twelve months, evidenced by poorer scores on POPC (p = 0.016), PCPC (p = 0.044), and VABS-II (p = 0.020). They were more likely to have a tracheostomy at hospital discharge (p = 0.034), require supplemental oxygen at three months (p = 0.039) and twelve months (p = 0.034), and be mechanically ventilated at twelve months (p = 0.041).

CONCLUSIONS

There was no difference in survival to 28 days following OHCA in children with pre-existing comorbidity compared to previously healthy children. The group with pre-existing comorbidity was more reliant on technology following arrest and exhibited worse neurobehavioral outcomes.

Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification

BACKGROUND

Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics.

METHODS

In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management.

RESULTS

For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication.

CONCLUSION

Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.

Sociodemographic factors associated with paediatric out-of-hospital cardiac arrest: A systematic review

BACKGROUND

Paediatric out-of-hospital cardiac arrest (POHCA) is associated with poor survival and severe neurological sequelae. We conducted a systematic review on the impact of sociodemographic factors across different stages of POHCA.

METHODS

We searched MEDLINE, EMBASE, and Web of Science from database inception to October 2022. We included studies examining the association between sociodemographic factors (i.e., race, ethnicity, migrant status and socioeconomic status [SES]) and POHCA risk, bystander cardiopulmonary resuscitation (CPR) provision, bystander automated external defibrillator (AED) application, survival (at or 30-days post-discharge), and neurological outcome. We synthesized the data qualitatively.

RESULTS

We screened 11,097 citations and included 18 articles (arising from 15 studies). There were 4 articles reporting on POHCA risk, 5 on bystander CPR provision, 3 on bystander AED application, 13 on survival, and 6 on neurological outcome. In all studies on POHCA risk, significant differences were found across racial groups, with minority populations being disproportionately impacted. There were no articles reporting on the association between SES and POHCA risk. Bystander CPR provision was consistently associated with race and ethnicity, with disparities impacting Black and Hispanic children. The association between bystander CPR provision and SES was variable. There was little evidence of socioeconomic or racial disparities in studies on bystander AED application, survival, and neurological outcome, particularly across adjusted analyses.

CONCLUSIONS

Race and ethnicity are likely associated with POHCA risk and bystander CPR provision. These findings highlight the importance of prioritizing at-risk groups in POHCA prevention and intervention efforts. Further research is needed to understand underlying mechanisms.

Early Glycemic State and Outcomes of Neonates With Hypoxic-Ischemic Encephalopathy

OBJECTIVES

In infants with hypoxic-ischemic encephalopathy (HIE), conflicting information on the association between early glucose homeostasis and outcome exists. We characterized glycemic profiles in the first 12 hours after birth and their association with death and neurodevelopmental impairment (NDI) in neonates with moderate or severe HIE undergoing therapeutic hypothermia.

METHODS

This post hoc analysis of the High-dose Erythropoietin for Asphyxia and Encephalopathy trial included n = 491 neonates who had blood glucose (BG) values recorded within 12 hours of birth. Newborns were categorized based on their most extreme BG value. BG >200 mg/dL was defined as hyperglycemia, BG <50 mg/dL as hypoglycemia, and 50 to 200 mg/dL as euglycemia. Primary outcome was defined as death or any NDI at 22 to 36 months. We calculated odds ratios for death or NDI adjusted for factors influencing glycemic state (aOR).

RESULTS

Euglycemia was more common in neonates with moderate compared with severe HIE (63.6% vs 36.6%; P < .001). Although hypoglycemia occurred at similar rates in severe and moderate HIE (21.4% vs 19.5%; P = .67), hyperglycemia was more common in severe HIE (42.3% vs 16.9%; P < .001). Compared with euglycemic neonates, both, hypo- and hyperglycemic neonates had an increased aOR (95% confidence interval) for death or NDI (2.62; 1.47-4.67 and 1.77; 1.03-3.03) compared to those with euglycemia. Hypoglycemic neonates had an increased aOR for both death (2.85; 1.09-7.43) and NDI (2.50; 1.09-7.43), whereas hyperglycemic neonates had increased aOR of 2.52 (1.10-5.77) for death, but not NDI.

CONCLUSIONS

Glycemic profile differs between neonates with moderate and severe HIE, and initial glycemic state is associated death or NDI at 22 to 36 months.

Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation

AIM

This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival.

METHODS

Data from the German Resuscitation Registry (GRR) were used, and we included patients registered between 1st January 2007 and 31st December 2021. We included children aged between > 7 days and 17 years, where cardiopulmonary resuscitation (CPR) was started, and treatment was continued by emergency medical services (EMS). Incidences and descriptive analyses are presented for the overall cohort and each age group. Multivariate binary logistic regression was performed on the whole cohort to determine the influence of (1) CPR with/without ventilation started by bystander, (2) OHCA witnessed status and (3) night-time on the outcome hospital admission with return of spontaneous circulation (ROSC).

RESULTS

OHCA in children aged < 1 year had the highest incidence of the same age group, with 23.42 per 100 000. Overall, hypoxia was the leading presumed cause of OHCA, whereas trauma and drowning accounted for a high proportion in children aged > 1 year. Bystander-witnessed OHCA and bystander CPR rate were highest in children aged 1-4 years, with 43.9% and 62.3%, respectively. In reference to EMS-started CPR, bystander CPR with ventilation were associated with an increased odds ratio for ROSC at hospital admission after adjusting for age, sex, year of OHCA and location of OHCA.

CONCLUSION

This study provides an epidemiological overview of OHCA in children in Germany and identifies bystander CPR with ventilation as one primary factor for survival. Trial registrations German Clinical Trial Register: DRKS00030989, December 28th 2022.

Hospital ECMO capability is associated with survival in pediatric cardiac arrest

AIM

Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital.

METHODS

We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival.

RESULTS

We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support.

CONCLUSION

A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.

Arterial Blood Gas Analysis for Survival Prediction in Pediatric Patients with Out-of-Hospital Cardiac Arrest

Arterial blood gas analysis (ABGA) is one of the few tests performed during cardiopulmonary resuscitation (CPR). There have been some studies on the prediction of survival outcomes in adult out-of-hospital cardiac arrest (OHCA) patients during CPR using ABGA results. However, in pediatric OHCA patients, the prognosis of survival outcome based on ABGA results during CPR remains unclear. We retrospectively analyzed prospectively collected data from the Korean Cardiac Arrest Resuscitation Consortium (KoCARC) registry, a multicenter OHCA registry of Republic of Korea. We analyzed 108 pediatric (age < 19 years) OHCA patients between October 2015 and June 2022. Using multivariable logistic regression, an adjusted odds ratio (aOR) was obtained to validate the ABGA results of survival to hospital admission and survival to discharge. The variables associated with survival to hospital admission were non-comorbidities (aOR 3.03, 95% confidence interval (CI) 1.22-7.53, p = 0.017) and PaO₂ > 45.750 mmHg (aOR 2.69, 95% CI 1.13-6.42, p = 0.026). There was no variable that was statistically significant association with survival to discharge. PaO₂ > 47.750 mmHg and non-comorbidities may serve as an independent prognostic factor for survival to hospital admission in pediatric OHCA patients. However, the number of cases analyzed in our study was relatively small, and there have been few studies investigating the association between ABGA results during CPR and the survival outcome of pediatric OHCA patients. Therefore, further large-scale studies are needed.

Global burden of out-of-hospital cardiac arrest in children: a systematic review, meta-analysis, and meta-regression

The incidence of out-of-hospital cardiac arrest (OHCA) and its mortality among children decreased globally over the years. However, the incidence, mortality, and its determinants are heterogeneous globally. The current study was designed to investigate the incidence of OHCA, mortality, and its determinants based on a systematic review of published literature. A comprehensive search was conducted in PubMed/Medline; Science Direct, Cochrane Library, Hinari, and LILACS without language and date restrictions. The data were extracted with two independent authors in a customized format. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa appraisal tool. A total of 2526 articles were identified from different databases with an initial search. Forty-eight articles with 138.3 million participants were included in the systematic review. The meta-analysis showed that the pooled rate of mortality was found to be 70% (95% CI: 57-81%, 42 studies, 28,345 participants). The incidence of OHCA and mortality among children was very high among children with significant regional disparity. Those children with cardiovascular causes of arrest, and initial nonshockable rhythm were independent predictors of OHCA-related mortality. This systematic review and meta-analysis is registered in Prospero (CRD42022316602). IMPACT: This systematic review addresses a significant health problem in a global context from 1995 to 2022. The meta-regression revealed that the incidence of OHCA and mortality of children decline over the years in high-income countries despite regional dispraises among individual studies. Body of evidence on the incidence of OHCA and mortality is lacking in low- and middle-income countries.

Survival Rates After Pediatric Traumatic Out-of-Hospital Cardiac Arrest Suggest an Underappreciated Therapeutic Opportunity

OBJECTIVES

Children with traumatic arrests represent almost one third of annual pediatric out-of-hospital cardiac arrests (OHCAs). However, traumatic arrests are often excluded from study populations because survival posttraumatic arrest is thought to be negligible. We hypothesized that children treated and transported by emergency medical services (EMS) personnel after traumatic OHCA would have lower survival compared with children treated after medical OHCA.

METHODS

We performed a secondary, observational study of children younger than 18 years treated and transported by 78 EMS agencies in southwestern Pennsylvania after OHCA from 2010 to 2014. Etiology was determined as trauma or medical by EMS services. We analyzed patient, cardiac arrest, and resuscitation characteristics and ascertained vital status using the National Death Index. We used multivariable logistic regression to test the association of etiology with mortality after covariate adjustment.

RESULTS

Forty eight of 209 children (23%) had traumatic OHCA. Children with trauma were older than those with medical OHCA (13.2 [3.8-15.9] vs 0.5 [0.2-2.4] years, P < 0.001). Prehospital return of spontaneous circulation frequency for trauma versus medical etiology was similar (90% vs 87%, P = 0.84). Patients with trauma had higher mortality (69% vs 45% P = 0.004).

CONCLUSIONS

More than 8 of 10 children with EMS treated and transported OHCA achieved return of spontaneous circulation. Despite lower survival rates than medical OHCA patients, almost one third of children with a traumatic etiology survived throughout the study period. Future research programs warrant inclusion of children with traumatic OHCA to improve outcomes.

A chart review tool to systematically assess the safety of prehospital care for children with out‐of‐hospital cardiac arrest

Objective

Create an easy‐to‐use pediatric out‐of‐hospital cardiac arrest (OHCA)‐specific chart review tool to reliably detect severe adverse safety events (ASEs) in the prehospital care of children with OHCA.

Methods

We revised our previously validated pediatric prehospital adverse event detection system (PEDS) tool, used to evaluate ASEs in the prehospital care of children during emergent calls, to create an OHCA‐specific chart review tool. We developed decision support for reviewers, reviewer training, and a dedicated section for chart data abstraction. We randomly selected 28 charts for independent review by 2 expert reviewers who determined the presence or absence of a severe ASE for each care episode and identified the domain of care and preventability for each ASE. We calculated inter‐rater agreement in the assessment of the presence or absence of a severe ASE using Gwet's first‐order agreement coefficient (AC1).

Results

The PEDS‐OHCA chart review tool has 6 sections, with a minimum of 70 and maximum of 667 total possible fields. We found inter‐rater agreement of 0.83 (95% confidence interval, 0.63–0.99) between our 2 reviewers for the overall detection of a severe ASE and an average time to complete of 8 minutes (range, 2–25 minutes). Inter‐rater agreement in the detection of a severe ASE in each individual domain ranged from 0.36 to 0.96.

Conclusions

The PEDS‐OHCA is the first chart review tool to systematically evaluate the safety and quality of EMS care for children with OHCA. This tool may help improve understanding of the quality of EMS care for children with OHCA, which is essential to improving outcomes.

Evaluation of Local Pediatric Out-of-Hospital Cardiac Arrest and Emergency Services Response

Background

Survival after pediatric out-of-hospital cardiac arrest is poor. Paramedic services provide critical interventions that impact survival outcomes. We aimed to describe local pediatric out-of-hospital cardiac arrest (POHCA) events and evaluate the impact of the paramedic service response to POHCA.

Methods

The Canadian Resuscitation Outcomes Consortium and corresponding ambulance call records were used to evaluate deviations from best practice by paramedics for patients aged 1 day to <18 years who had an atraumatic out-of-hospital cardiac arrest between 2012 and 2020 in Middlesex-London County. Deviations were any departure from protocol as defined by Middlesex-London Paramedic Services.

Results

Fifty-one patients were included in this study. All POHCA events had at least one deviation, with a total of 188 deviations for the study cohort. Return of spontaneous circulation (ROSC) was achieved in 35.3% of patients and 5.8% survived to hospital discharge. All survivors developed a new, severe neurological impairment. Medication deviations were most common (n = 40, 21.3%) followed by process timing (n = 38, 20.2%), vascular access (n = 27, 14.4%), and airway (n = 27, 14.4%). A delay in vascular access was the most common deviation (n = 25, 49.0%). The median (IQR) time to epinephrine administration was 8.6 (5.90-10.95) min from paramedic arrival. Cardiac arrests occurring in public settings had more deviations than private settings (p = 0.04). ROSC was higher in events with a deviation in any circulation category (p = 0.03).

Conclusion

Patient and arrest characteristics were similar to other POHCA studies. This cohort exhibited high rates of ROSC and bystander cardiopulmonary resuscitation but low survival to hospital discharge. The study was underpowered for its primary outcome of survival. The total deviations scored was low relative to the total number of tasks in a resuscitation. Epinephrine was frequently administered outside of the recommended timeframe, highlighting an important quality improvement opportunity.

Functional Restoration following Global Cerebral Ischemia in Juvenile Mice following Inhibition of Transient Receptor Potential M2 (TRPM2) Ion Channels

Hippocampal cell death and cognitive dysfunction are common following global cerebral ischemia across all ages, including children. Most research has focused on preventing neuronal death. Restoration of neuronal function after cell death is an alternative approach (neurorestoration). We previously identified transient receptor potential M2 (TRPM2) ion channels as a potential target for acute neuroprotection and delayed neurorestoration in an adult CA/CPR mouse model. Cardiac arrest/cardiopulmonary resuscitation (CA/CPR) in juvenile (p20-25) mice was used to investigate the role of ion TRPM2 channels in neuroprotection and ischemia-induced synaptic dysfunction in the developing brain. Our novel TRPM2 inhibitor, tatM2NX, did not confer protection against CA1 pyramidal cell death but attenuated synaptic plasticity (long-term plasticity (LTP)) deficits in both sexes. Further, in vivo administration of tatM2NX two weeks after CA/CPR reduced LTP impairments and restored memory function. These data provide evidence that pharmacological synaptic restoration of the surviving hippocampal network can occur independent of neuroprotection via inhibition of TRPM2 channels, providing a novel strategy to improve cognitive recovery in children following cerebral ischemia. Importantly, these data underscore the importance of age-appropriate models in disease research.

Precision Cardiac Arrest Resuscitation Based on Etiology

Cardiac arrest results from a broad range of etiologies that can be broadly grouped as sudden and asphyxial. Animal studies point to differences in injury pathways invoked in the heart and brain that drive injury and outcome after these different forms of cardiac arrest. Present guidelines largely ignore etiology in their management recommendations. Existing clinical data reveal significant heterogeneity in the utility of presently employed resuscitation and postresuscitation strategies based on etiology. The development of future neuroprotective and cardioprotective therapies should also take etiology into consideration to optimize the chances for successful translation.

Longitudinal two years evaluation of neuropsychological outcome in children after out of hospital cardiac arrest

AIM

To investigate longitudinal functional and neuropsychological outcomes 3-6 and 24 months after paediatric out-of-hospital cardiac arrest (OHCA). Further, to explore the association between paediatric cerebral performance category (PCPC) and intelligence.

METHODS

Prospective longitudinal single center study including children (0-17 years) with OHCA, admitted to the PICU of a tertiary care hospital between 2012 and 2017. Survivors were assessed during an outpatient multidisciplinary follow-up program 3-6 and 24 months post-OHCA. Functional and neuropsychological outcomes were assessed through interviews, neurological exam, and validated neuropsychological testing.

RESULTS

The total eligible cohort consisted of 49 paediatric OHCA survivors. The most common cause of OHCA was arrhythmia (33%). Median age at time of OHCA was 48 months, 67% were males. At 3-6 and 24 months post-OHCA, respectively 74 and 73% had a good PCPC score, defined as 1-2. Compared with normative data, OHCA children obtained worse sustained attention and processing speed scores 3-6 (n = 26) and 24 (n = 27) months post-OHCA. At 24 months, they also obtained worse intelligence, selective attention and cognitive flexibility scores. In children tested at both time-points (n = 19), no significant changes in neuropsychological outcomes were found over time. Intelligence scores did not correlate with PCPC.

CONCLUSION

Although paediatric OHCA survivors had a good PCPC score 3-6 and 24 months post-OHCA, they obtained worse scores on important neuropsychological domains such as intelligence and executive functioning (attention and cognitive flexibility). Follow-up should continue over a longer life span in order to fully understand the long-term impact of OHCA in childhood.

Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA

In an era of tremendous medical advancements, it is important to characterise and address inequities in the provision of health care and in outcomes. There is a large body of evidence describing such disparities by race or ethnicity and socioeconomic position in critically ill adults; however, this important issue has received less attention in children and adolescents (aged ≤21 years). This Review presents a summary of the available evidence on disparities in outcomes in paediatric critical illness in the USA as a result of racism and socioeconomic privilege. The majority of evidence of racial and socioeconomic disparities in paediatric critical care originates from the USA and is retrospective, with only one prospective intervention-based study. Although there is mixed evidence of disparities by race or ethnicity and socioeconomic position in general paediatric intensive care unit admissions and outcomes in the USA, there are striking trends within some disease processes. Notably, there is evidence of disparities in management and outcomes for out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and oncology, and in families' perceptions of care. Furthermore, there is clear evidence that critical care research is limited by under-enrolment of participants from minority race or ethnicity groups. We advocate for rigorous research standards and increases in the recruitment and enrolment of a diverse range of participants in paediatric critical care research to better understand the disparities observed, including the effects of racism and poverty. A clearer understanding of when, where, and how such disparities affect patients will better enable the development of effective strategies to inform practice, interventions, and policy.

Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis

BACKGROUND

Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system.

RESULTS

We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25-0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the "before 2010" subgroup (OR 0.47; 95% CI 0.30-0.73; p value = 0.006) and the "after 2010" subgroup (OR 0.46; 95% CI 0.25-0.87; p value = 0.02). The certainty of evidence ranged from very low to low.

CONCLUSIONS

This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations.

TRIAL REGISTRATION

The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).

Timing and Cause of Death in Children Following Return of Circulation After Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Cohort Study

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.

Associations between initial serum pH value and outcomes of pediatric out-of-hospital cardiac arrest

INTRODUCTION

Pediatric out-of-hospital cardiac arrest (OHCA) is one of the most critical conditions seen in the emergency department (ED). Although initial serum pH value is reported to be associated with outcome in adult OHCA patients, the association is unclear in pediatric OHCA patients. Thus, we aimed to identify the association between initial pH value and outcome among pediatric OHCA patients.

METHODS

This study was a retrospective analysis of a multicenter prospective cohort registry (Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry) from 87 hospitals in Japan. We included pediatric OHCA patients younger than 16 years of age who were registered in this registry between June 2014 and December 2017. Of the 34,754 patients in the database, 458 patients were ultimately included in the analysis. We equally divided the patients into four groups, based on their initial pH value, and conducted a multivariate logistic regression analysis to calculate the adjusted odds ratios of the initial pH value on hospital arrival with their 95% confidence intervals for the primary outcome.

RESULTS

The median (interquartile range) age was 1 (0-6) year, and 77.9% (357/458) of the first monitored rhythm was asystole. The primary outcome was 1-month survival. The overall 1-month survival was 13.3% (61/458), and a 1-month favorable neurologic outcome was seen in 5.2% (24/458) of cases. The adjusted odds ratios and 95% confidence intervals for the pH 6.81-6.64, pH 6.63-6.47, pH <6.47, and pH unknown groups compared with the pH ≥6.82 group for 1-month survival were 0.39 (0.16-0.97), 0.13 (0.04-0.44), 0.03 (0.00-0.24), and 0.07 (0.02-0.21), respectively.

CONCLUSIONS

This study demonstrated the association between the initial pH value on hospital arrival and 1-month survival among pediatric OHCA patients.

A Systematic Review of Neuromonitoring Modalities in Children Beyond Neonatal Period After Cardiac Arrest

OBJECTIVES

Postresuscitation care in children focuses on preventing secondary neurologic injury and attempts to provide (precise) prognostication for both caregivers and the medical team. This systematic review provides an overview of neuromonitoring modalities and their potential role in neuroprognostication in postcardiac arrest children.

DATA RESOURCES

Databases EMBASE, Web of Science, Cochrane, MEDLINE Ovid, Google Scholar, and PsycINFO Ovid were searched in February 2019.

STUDY SELECTION

Enrollment of children after in- and out-of-hospital cardiac arrest between 1 month and 18 years and presence of a neuromonitoring method obtained within the first 2 weeks post cardiac arrest. Two reviewers independently selected appropriate studies based on the citations.

DATA EXTRACTION

Data collected included study characteristics and methodologic quality, populations enrolled, neuromonitoring modalities, outcome, and limitations. Evidence tables per neuromonitoring method were constructed using a standardized data extraction form. Each included study was graded according to the Oxford Evidence-Based Medicine scoring system.

DATA SYNTHESIS

Of 1,195 citations, 27 studies met the inclusion criteria. There were 16 retrospective studies, nine observational prospective studies, one observational exploratory study, and one pilot randomized controlled trial. Neuromonitoring methods included neurologic examination, routine electroencephalography and continuous electroencephalography, transcranial Doppler, MRI, head CT, plasma biomarkers, somatosensory evoked potentials, and brainstem auditory evoked potential. All evidence was graded 2B-2C.

CONCLUSIONS

The appropriate application and precise interpretation of available modalities still need to be determined in relation to the individual patient. International collaboration in standardized data collection during the (acute) clinical course together with detailed long-term outcome measurements (including functional outcome, neuropsychologic assessment, and health-related quality of life) are the first steps toward more precise, patient-specific neuroprognostication after pediatric cardiac arrest.

NEUROlogical Prognosis After Cardiac Arrest in Kids (NEUROPACK) study: protocol for a prospective multicentre clinical prediction model derivation and validation study in children after cardiac arrest

INTRODUCTION

Currently, we are unable to accurately predict mortality or neurological morbidity following resuscitation after paediatric out of hospital (OHCA) or in-hospital (IHCA) cardiac arrest. A clinical prediction model may improve communication with parents and families and risk stratification of patients for appropriate postcardiac arrest care. This study aims to the derive and validate a clinical prediction model to predict, within 1 hour of admission to the paediatric intensive care unit (PICU), neurodevelopmental outcome at 3 months after paediatric cardiac arrest.

METHODS AND ANALYSIS

A prospective study of children (age: >24 hours and <16 years), admitted to 1 of the 24 participating PICUs in the UK and Ireland, following an OHCA or IHCA. Patients are included if requiring more than 1 min of cardiopulmonary resuscitation and mechanical ventilation at PICU admission Children who had cardiac arrests in PICU or neonatal intensive care unit will be excluded. Candidate variables will be identified from data submitted to the Paediatric Intensive Care Audit Network registry. Primary outcome is neurodevelopmental status, assessed at 3 months by telephone interview using the Vineland Adaptive Behavioural Score II questionnaire. A clinical prediction model will be derived using logistic regression with model performance and accuracy assessment. External validation will be performed using the Therapeutic Hypothermia After Paediatric Cardiac Arrest trial dataset. We aim to identify 370 patients, with successful consent and follow-up of 150 patients. Patient inclusion started 1 January 2018 and inclusion will continue over 18 months.

ETHICS AND DISSEMINATION

Ethical review of this protocol was completed by 27 September 2017 at the Wales Research Ethics Committee 5, 17/WA/0306. The results of this study will be published in peer-reviewed journals and presented in conferences.

TRIAL REGISTRATION NUMBER

NCT03574025.

Pediatric Cardiac Arrest Resuscitation

Pediatric cardiac arrest is a relatively rare but devastating presentation in infants and children. In contrast to adult patients, in whom a primary cardiac dysrhythmia is the most likely cause of cardiac arrest, pediatric patients experience cardiovascular collapse most frequently after an initial respiratory arrest. Aggressive treatment in the precardiac arrest state should be initiated to prevent deterioration and should focus on support of oxygenation, ventilation, and hemodynamics, regardless of the presumed cause. Unfortunately, outcomes for pediatric cardiac arrest, whether in hospital or out of hospital, continue to be poor.

Brain MR imaging and spectroscopy for outcome prognostication after pediatric cardiac arrest

AIM

Children surviving cardiac arrest are at high risk of neurological morbidity and mortality; however, there is a lack of validated prognostic biomarkers. We aimed to evaluate brain magnetic resonance imaging (MRI) and spectroscopy (MRS) as predictors of death and disability. Secondly, we evaluated whether MRI/S by randomized group.

METHODS

This single center study analyzed clinically indicated brain MRI/S data from children enrolled in a randomized controlled trial of 24 vs. 72 h of hypothermia following cardiac arrest. Two pediatric radiologists scored conventional MRIs. Lactate and N-acetyl-aspartate (NAA) concentrations (mmol/kg) were determined from spectra acquired from the basal ganglia, thalamus, parietal white matter and parietooccipital gray matter. Mortality and neurological outcomes (favorable = Pediatric Cerebral Performance Category [PCPC] 1, 2, 3 or increase < 2) were assessed at hospital discharge. Non-parametric tests were used to test for associations between MRI/S biomarkers and outcome and randomized group.

RESULTS

23 children with (median [interquartile range]) age of 1.5 (0.3-4.0) years. Ten (44%) had favorable outcome. There were more T2 brain lesions in the lentiform nuclei in children with unfavorable 12 (92%) vs. favorable 3 (33%) outcome, p = 0.007. Increased lactate and decreased NAA concentrations in the parietooccipital gray matter and decreased NAA in the parietal white matter were associated with unfavorable outcome (p's < 0.05). There were no differences for any biomarker by randomized group.

CONCLUSION

Regional cerebral and metabolic MRI/S biomarkers are predictive of neurological outcomes at hospital discharge in pediatric cardiac arrest and should undergo validation testing in a large sample.

Prognostic value of the delta neutrophil index in pediatric cardiac arrest

The delta neutrophil index (DNI), which reflects the ratio of circulating immature neutrophils, has been reported to be highly predictive of mortality in systemic inflammation. We investigated the prognostic significance of DNI value for early mortality and neurologic outcomes after pediatric cardiac arrest (CA). We retrospectively analyzed the data of eligible patients (<19 years in age). Among 85 patients, 55 subjects (64.7%) survived and 36 (42.4%) showed good outcomes at 30 days after CA. Cox regression analysis revealed that the DNI values immediately after the return of spontaneous circulation, at 24 hours and 48 hours after CA, were related to an increased risk for death within 30 days after CA (P < 0.001). A DNI value of higher than 3.3% at 24 hours could significantly predict both 30-day mortality (hazard ratio: 11.8; P < 0.001) and neurologic outcomes (odds ratio: 8.04; P = 0.003). The C statistic for multivariable prediction models for 30-day mortality (incorporating DNI at 24 hours, compression time, and serum sodium level) was 0.799, and the area under the receiver operating characteristic curve of DNI at 24 hours for poor neurologic outcome was 0.871. Higher DNI was independently associated with 30-day mortality and poor neurologic outcomes after pediatric CA.

Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

Clinical Survey and Predictors of Outcomes of Pediatric Out-of-Hospital Cardiac Arrest Admitted to the Emergency Department

Pediatric out-of-hospital cardiac arrest (OHCA) is a rare event with severe sequelae. Although the survival to hospital-discharge (STHD) rate has improved from 2–6% to 17.6–40.2%, only 1–4% of OHCA survivors have a good neurological outcome. This study investigated the characteristics of case management before and after admittance to the emergency department (ED) associated with outcomes of pediatric OHCA in an ED. This was a retrospective study of data collected from our ED resuscitation room logbooks dating from 2005 to 2016. All records of children under 18 years old with OHCA were reviewed. Outcomes of interest included sustained return of spontaneous circulation (SROSC), STHD, and neurological outcomes. From the 12-year study period, 152 patients were included. Pediatric OHCA commonly affects males (55.3%, n = 84) and infants younger than 1 year of age (47.4%, n = 72) at home (76.3%, n = 116). Most triggers of pediatric OHCA were respiratory in nature (53.2%, n = 81). Sudden infant death syndrome (SIDS) (29.6%, n = 45), unknown medical causes (25%, n = 38), and trauma (10.5%, n = 16) were the main causes of pediatric OHCA. Sixty-two initial cardiac rhythms at the scene were obtained, most of which were asystole and pulseless electrical activity (PEA) (93.5%, n/all: 58/62). Upon ED arrival, cardiopulmonary resuscitation (CPR) was continued for 32.66 ± 20.71 min in the ED and 34.9% (n = 53) gained SROSC. Among them, 13.8% (n = 21) achieved STHD and 4.6% (n = 7) had a favorable neurological outcome. In multivariate analyses, fewer ED epinephrine doses (p < 0.05), witness of OHCA (p = 0.001), and shorter ED CPR duration (p = 0.007) were factors that increased the rate of SROSC at the ED. A longer emergency medical service (EMS) scene interval (p = 0.047) and shorter ED CPR interval (p = 0.047) improved STHD.

Dispatcher-assisted cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest: A structured evaluation of communication issues using the SACCIA® safe communication typology

AIM

To evaluate communication issues during dispatcher-assisted cardiopulmonary resuscitation (DACPR) for paediatric out-of-hospital cardiac arrest in a structured manner to facilitate recommendations for training improvement.

METHODS

A retrospective observational study evaluated DACPR communication issues using the SACCIA^® Safe Communication typology (Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation). Telephone recordings of 31 cases were transcribed verbatim and analysed with respect to encoding, decoding and transactional communication issues.

RESULTS

Sixty SACCIA communication issues were observed in the 31 cases, averaging 1.9 issues per case. A majority of the issues were related to sufficiency (35%) and accuracy (35%) of communication between dispatcher and caller. Situation specific guideline application was observed in CPR practice, (co)counting and methods of compressions.

CONCLUSION

This structured evaluation identified specific issues in paediatric DACPR communication. Our training recommendations focus on situation and language specific guideline application and moving beyond verbal communication by utilizing the smart phone's functions. Prospective efforts are necessary to follow-up its translation into better paediatric DACPR outcomes.

Multimodal assessment using early brain CT and blood pH improve prediction of neurologic outcomes after pediatric cardiac arrest

BACKGROUND

Early prediction of neurologic prognosis in children resuscitated from cardiac arrest is a major challenge. This study aimed to investigate the usefulness of a combined model based on brain computed tomography (CT) and initial blood gas analysis to predict neurologic prognoses in pediatric patients after cardiac arrest.

METHODS

We retrospectively analyzed the medical records of patients resuscitated after cardiac arrest from 2000 to 2018. Patients aged one month to 18 years were included. Gray to white matter ratio (GWR), ambient cistern effacement (ACE), and blood gas analysis were studied. The primary outcome was neurological prognosis, which was evaluated using the Pediatric Cerebral Performance Category (PCPC) scale at discharge.

RESULTS

Of 97 resuscitated patients, 64 brain CT images were available. Fourteen patients had a good neurologic outcome (PCPC 1-3) and 50 patients a poor neurologic outcome (PCPC 4-6). The multimodal model (AUC 0.897) containing GWR of basal ganglia (BG), ACE, and blood pH was found to be superior for predicting poor neurologic prognosis than single variable models (AUC of GWR-BG: 0.744, ACE: 0.804, pH: 0.747). Interestingly, we found the GWR-BG cutoff value for specificity 100% differed significantly between patients <4 years (cutoff value: 1.08, p = 0.04) and ≥4 years (cutoff value: 1.18, p = 0.004).

CONCLUSIONS

The combination of GWR-BG, ambient cistern effacement, and blood pH was found to usefully predict neurological outcome in children resuscitated from cardiac arrest. In addition, the cutoff value of GWR-BG for the prediction of neurologic outcome was found to increase with age.

Combination of Early EEG, Brain CT, and Ammonia Level Is Useful to Predict Neurologic Outcome in Children Resuscitated From Cardiac Arrest

Purpose: Predicting neurologic prognosis in pediatric patients recovered after cardiac arrest is more difficult than in adults. This study hypothesized that a combination model of early electroencephalography, brain computed tomography (CT), and laboratory findings improve prediction performance of neurologic outcome in pediatric patients after cardiac arrest. Methods: We retrospectively analyzed the medical records of pediatric patients resuscitated after non-traumatic cardiac arrest. Clinical features, electroencephalography, gray matter to white matter attenuation ratio on brain CT, and laboratory findings were analyzed. The primary outcome was neurologic prognosis based on the Pediatric Cerebral Performance Category score. Results: Of 21 patients, seven (33.3%) were classified as a good neurologic outcome group and 14 (66.7%) were classified as a poor neurologic outcome group. The good outcome group was associated with a slow and disorganized electroencephalographic background pattern (P = 0.006), reactivity (P = 0.006), and electrographic seizures (P = 0.03). The frequency of a suppressed electroencephalographic background pattern was significantly higher in the poor outcome group (P = 0.006). The poor outcome group was also associated with a low level of gray matter to white matter attenuation ratio (P = 0.03) and hyperammonemia (P = 0.003). The area under curve of the combined model, consisting of electroencephalographic background, gray matter to white matter attenuation ratio, and ammonia was the highest at 0.959 (0.772-0.999) with a specificity of 100%. Conclusion: Unfavorable electroencephalographic background, low gray matter to white matter attenuation ratio on brain CT, and hyperammonemia are associated with poor neurologic outcome in children after cardiac arrest.

Demographics of Pediatric OHCA Survivors With Postdischarge Diseases: A National Population-Based Follow-Up Study

Background: Postdischarge diseases (PDDs) have been reported for adult survivors of out-of-hospital cardiac arrest (OHCA). However, the detailed demographics of pediatric OHCA survivors with PDDs are not well-documented, and information regarding functional survivors is particularly limited. We aimed to report detailed information on the PDDs of survivors of traumatic and non-traumatic pediatric OHCA using a national healthcare database. Methods: We retrospectively obtained data from the Taiwan government healthcare database (2011-2015). Information on the demographics of traumatic and non-traumatic pediatric OHCA survivors (<20 years) was obtained and reported. The patients who survived to discharge (survivors) and those classified as functional survivors were followed up for 1 year for the analysis of newly diagnosed PDDs. The time from discharge to PDD diagnosis was also reported. Results: A total of 2,178 non-traumatic and 288 traumatic OHCA pediatric cases were included. Among the non-traumatic OHCA survivors (n = 374, survival rate = 17.2%), respiratory tract (n = 270, 72.2%), gastrointestinal (n = 187, 50.0%), and neurological diseases (n = 167, 49.1%) were the three most common PDD categories, and in these three categories, the majority of PDDs were atypical/influenza pneumonia, non-infective acute gastroenteritis, and generalized/status epilepsy, respectively. Among the traumatic OHCA survivors (n = 21, survival rate = 7.3%), respiratory tract diseases (n = 17, 81.0%) were the most common, followed by skin or soft tissue (n = 14, 66.7%) diseases. Most functional survivors still suffered from neurological and respiratory tract diseases. Most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge. Conclusions: Respiratory tract (pneumonia), neurological (epilepsy), and skin or soft tissue (dermatitis) diseases were very common among both non-traumatic and traumatic OHCA survivors. More importantly, most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge.

Pediatric out-of-hospital cardiac arrest: Time to goal target temperature and outcomes

AIM

Although recent out-of-hospital cardiac arrest (CA) trials found no benefits of hypothermia versus normothermia targeted temperature management, preclinical models suggest earlier timing of hypothermia improves neuroprotective efficacy. This study investigated whether shorter time to goal temperature was associated with better one-year outcomes in the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital Trial.

METHODS

Patients were classified by tertiles of time to attain assigned goal temperature range (32-34°C or 36-37.5°C) following ROSC. Outcomes in the first tertile ("earlier") Group 1 were compared with second and third tertiles ("later") Group 2. Separate analyses were, additionally, completed for hypothermia and normothermia intervention groups. Three one-year outcomes were examined: survival; Vineland Adaptive Behavior Scale (VABS-II) score≥70; and decrease in VABS-II≤15 points from baseline.

RESULTS

In the entire cohort (n=281), median time from ROSC to goal temperature was 7.4 [IQR 6.2-9.7] hours: Group 1, 5.8 [IQR 5.2, 6.2] and Group 2, 8.8 [IQR 7.4, 10.4] h. Outcomes did not differ between these groups. For hypothermia subgroup, survival was lower in Group 1 than 2, [10/49(20%) versus 47/99(47%), p<0.002], with a trend toward fewer with VABS-II scores≥70 and change in VABS-II≤15 points (p=0.07-0.08). For normothermia subgroup, there was a trend toward higher survival in Group 1 than 2 [18/42(43%) versus 21/83(25%), p=0.065], but no differences in VABS-II-related measures. In multivariable logistic regression models, no difference in earlier and later groups or temperature intervention was observed.

CONCLUSION

We found no evidence that earlier time to goal temperature was associated with better outcomes.

Juvenile cerebral ischemia reveals age-dependent BDNF-TrkB signaling changes: Novel mechanism of recovery and therapeutic intervention

Global ischemia in childhood often leads to poor neurologic outcomes, including learning and memory deficits. Using our novel model of childhood cardiac arrest/cardiopulmonary resuscitation (CA/CPR), we investigate the mechanism of ischemia-induced cognitive deficits and recovery. Memory is impaired seven days after juvenile CA/CPR and completely recovers by 30 days. Consistent with this remarkable recovery not observed in adults, hippocampal long-term potentiation (LTP) is impaired 7-14 days after CA/CPR, recovering by 30 days. This recovery is not due to the replacement of dead neurons (neurogenesis), but rather correlates with brain-derived neurotrophic factor (BDNF) expression, implicating BDNF as the molecular mechanism underlying impairment and recovery. Importantly, delayed activation of TrkB receptor signaling reverses CA/CPR-induced LTP deficits and memory impairments. These data provide two new insights (1) endogenous recovery of memory and LTP through development may contribute to improved neurological outcome in children compared to adults and (2) BDNF-enhancing drugs speed recovery from pediatric cardiac arrest during the critical school ages.

Varicella zoster in sudden infant death

A 2-month-old girl with normal development and no previous physical illnesses was resuscitated having been found lifeless on her back at home. On admission to Paediatric Intensive Care, she had severe metabolic disturbance, associated with an extremely troubling neurological signs. She died 2 hours later. A full body CT scan did not reveal injury and her parents declined an autopsy. Peripheral blood and cerebrospinal fluid samples were sterile. However, a broad-range PCR coupled with electrospray-ionisation mass spectrometry onto the PLEX-ID automat of peripheral blood revealed the presence of varicella zoster virus. There was a specific viral load in whole blood of 20 542 copies/ml. It is presumed that Varicella myocarditis was the likely cause of death. Our case illustrates the potential usefulness of a broad range PCR strategy in determining infectious causes of death in sudden infant death. Varicella is a potential cause of sudden infant death.

Therapeutic hypothermia after paediatric cardiac arrest: Pooled randomized controlled trials

BACKGROUND

Separate trials to evaluate therapeutic hypothermia after paediatric cardiac arrest for out-of-hospital and in-hospital settings reported no statistically significant differences in survival with favourable neurobehavioral outcome or safety compared to therapeutic normothermia. However, larger sample sizes might detect smaller clinical effects. Our aim was to pool data from identically conducted trials to approximately double the sample size of the individual trials yielding greater statistical power to compare outcomes.

METHODS

Combine individual patient data from two clinical trials set in forty-one paediatric intensive care units in USA, Canada and UK. Children aged at least 48 h up to 18 years old, who remained comatose after resuscitation, were randomized within 6 h of return of circulation to hypothermia or normothermia (target 33.0 °C or 36.8 °C). The primary outcome, survival 12 months post-arrest with Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score at least 70 (scored from 20 to 160, higher scores reflecting better function, population mean = 100, SD = 15), was evaluated among patients with pre-arrest scores ≥70.

RESULTS

624 patients were randomized. Among 517 with pre-arrest VABS-II scores ≥70, the primary outcome did not significantly differ between hypothermia and normothermia groups (28% [75/271] and 26% [63/246], respectively; relative risk, 1.08; 95% confidence interval [CI], 0.81 to 1.42; p = 0.61). Among 602 evaluable patients, the change in VABS-II score from baseline to 12 months did not differ significantly between groups (p = 0.20), nor did, proportion of cases with declines no more than 15 points or improvement from baseline [22% (hypothermia) and 21% (normothermia)]. One-year survival did not differ significantly between hypothermia and normothermia groups (44% [138/317] and 38% [113/ 297], respectively; relative risk, 1.15; 95% CI, 0.95 to 1.38; p = 0.15). Incidences of blood-product use, infection, and serious cardiac arrhythmia adverse events, and 28-day mortality, did not differ between groups.

CONCLUSIONS

Analysis of combined data from two paediatric cardiac arrest targeted temperature management trials including both in-hospital and out-of-hospital cases revealed that hypothermia, as compared with normothermia, did not confer a significant benefit in survival with favourable functional outcome at one year.

72-h therapeutic hypothermia improves neurological outcomes in paediatric asphyxial out-of-hospital cardiac arrest-An exploratory investigation

BACKGROUND

Recent studies suggest that a 48-h therapeutic hypothermia protocol does not improve outcomes in paediatric out-of-hospital cardiac arrest survivors. The aim of this study was to evaluate the effect of 72-h therapeutic hypothermia at 33 °C compared to normothermia at 35.5 °C-37.5 °C on outcomes and the incidence of adverse events in paediatric asphyxial out-of-hospital cardiac arrest survivors.

METHODS

We conducted this retrospective cohort study at a tertiary paediatric intensive care unit between January 2010 and June 2017. All children from 1 month to 18 years of age with asphyxial out-of-hospital cardiac arrest and a history of at least 3 min of chest compressions who survived for 12 h or more after the return of circulation were eligible.

RESULTS

Sixty-four patients met the eligibility criteria for the study. Forty-nine (76.6%) of the 64 children were male, and the mean age was 4.86+/-5.26 years. Twenty-four (37.5%) of the children had underlying disorders. The overall 1-month survival rate was 43.2%. Twenty-five (39.1%) of the children received therapeutic hypothermia at 33 °C for 72 h. The 1-month survival rate was significantly higher (p = 0.037) in the therapeutic hypothermia group (15/25, 60%) than in the normothermia group (12/39, 30.8%). The therapeutic hypothermia group had significantly better neurological outcomes (7/15, 46.7%) than the normothermia group (1/12, 8.3%) (p = 0.043).

CONCLUSION

Paediatric asphyxial out-of-hospital cardiac arrest was associated with high mortality and morbidity. Seventy-two-hour therapeutic hypothermia was associated with a better 1-month survival rate and 6-month neurological outcomes than normothermia in our paediatric patients with asphyxial out-of-hospital cardiac arrest.

Timing and modes of death after pediatric out-of-hospital cardiac arrest resuscitation

AIM

To determine the timing and modes of death of children admitted to a pediatric critical care unit (PICU) of a tertiary care center after an out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective descriptive study at a tertiary care PICU of all consecutive patients <18 years old who received ≥1 min of chest compressions, had return of spontaneous circulation (ROSC) for ≥20 min, and were admitted to the PICU after an OHCA. Modes of death were classified as brain death (BD), withdrawal due to neurologic prognosis (W/D-neuro), withdrawal for refractory circulatory failure (W/D-RCF), and re-arrest without ROSC (RA).

RESULTS

191 consecutive patients were admitted to the PICU from February 2005 to May 2013 after an OHCA. Eighty-six(45%) patients died prior to discharge: BD in 47%(40/86), W/D-neuro in 34%(29/86), W/D-RCF in 10%(9/86), and RA in 9%(8/86). Time to death was longer for patients with W/D-neuro: 4 days [1, 5] and BD 4 days [1, 5](p < 0.01) as opposed to those with W/D-RCF (1 day[1, 2]) and RA(1 day[0.5, 1]). Of patients who underwent W/D-neuro, 9/29(31%) died within 3 days of PICU admission and 20/29(69%) ≥3 days. Of patients who died after W/D-neuro, 12/29(41%) received therapeutic hypothermia, 27/29(93%) underwent EEG monitoring, 21/29(72%) had a brain CT, and 13/29(45%) had a brain MRI. All MRIs showed signs of hypoxic-ischemic injury.

CONCLUSION

Neurologic injury was the most common mode of death post-resuscitation care OHCA after in a tertiary care center PICU. Neurologic prognostication impacts the outcome of a large proportion of patients after OHCA, and further studies are warranted to improve its reliability.

Burden of caregiving after a child's in-hospital cardiac arrest

OBJECTIVE

To describe caregiver burden among those whose children survive in-hospital cardiac arrest and have high risk of neurologic disability, and explore factors associated with burden during the first year post-arrest.

METHODS

The study is a secondary analysis of the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial. 329 children who had an in-hospital cardiac arrest, chest compressions for >2 min, and mechanical ventilation after return of circulation were recruited to THAPCA-IH. Of these, 155 survived to one year, and caregivers of 138 were assessed for burden. Caregiver burden was assessed at baseline, and 3 and 12 months post-arrest using the Infant Toddler Quality of Life Questionnaire for children <5 years old and the Child Health Questionnaire for children >5 years. Child functioning was assessed using the Vineland Adaptive Behaviour Scales Second Edition (VABS-II), the Paediatric Overall Performance Category (POPC) and Paediatric Cerebral Performance Category (PCPC) scales, and caregiver perception of global functioning.

RESULTS

Of 138 children, 77 (55.8%) were male, 77 (55.8%) were white, and 109 (79.0%) were <5 years old at the time of arrest. Caregiver burden was greater than reference norms at all time points. Worse POPC, PCPC and VABS-II scores at 3 months post-arrest were associated with greater caregiver burden at 12 months. Worse global functioning at 3 months was associated with greater burden at 12 months for children <5 years.

CONCLUSIONS

Caregiver burden is substantial during the first year after paediatric in-hospital cardiac arrest, and associated with the extent of the child's neurobehavioural dysfunction.

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.