Cerebral Oximetry During Pediatric In-Hospital Cardiac Arrest: A Multicenter Study of Survival and Neurologic Outcome

OBJECTIVES

To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children.

DESIGN

Multicenter, observational study.

SETTING

Three hospitals in the pediatric Resuscitation Quality (pediRES-Q) collaborative from 2015 to 2022.

PATIENTS

Children younger than 18 years, gestational age 37 weeks old or older with in-hospital cardiac arrest (IHCA) receiving cardiopulmonary resuscitation greater than or equal to 1 minute and intra-arrest crS o2 monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was ROSC greater than or equal to 20 minutes without extracorporeal membrane oxygenation. Secondary outcomes included SHD and favorable neurologic outcome (FNO) (Pediatric Cerebral Performance Category 1-2 or no change from prearrest). Among 3212 IHCA events (index and nonindex), 123 met inclusion criteria in 93 patients. Median age was 0.3 years (0.1-1.4 yr) and 31% (38/123) of the cardiopulmonary resuscitation events occurred in patients with cyanotic heart disease. Median cardiopulmonary resuscitation duration was 8 minutes (3-28 min) and ROSC was achieved in 65% (80/123). For index events, SHD was achieved in 59% (54/91) and FNO in 41% (37/91). We determined the association of median intra-arrest crS o2 and percent of crS o2 values above a priori thresholds during the: 1) entire cardiopulmonary resuscitation event, 2) first 5 minutes, and 3) last 5 minutes with ROSC, SHD, and FNO. Higher crS o2 for the entire cardiopulmonary resuscitation event, first 5 minutes, and last 5 minutes were associated with higher likelihood of ROSC, SHD, and FNO. In multivariable analysis of the infant group (age < 1 yr), higher crS o2 was associated with ROSC (odds ratio [OR], 1.06; 95% CI, 1.03-1.10), SHD (OR, 1.04; 95% CI, 1.01-1.07), and FNO (OR, 1.05; 95% CI, 1.02-1.08) after adjusting for presence of cyanotic heart disease.

CONCLUSIONS

Higher crS o2 during pediatric IHCA was associated with increased rate of ROSC, SHD, and FNO. Intra-arrest crS o2 may have a role as a real-time, noninvasive predictor of ROSC.

The association of recent simulation training and clinical experience of team leaders with cardiopulmonary resuscitation quality during in-hospital cardiac arrest

OBJECTIVE

We aimed to investigate the association of recent team leader simulation training (<6 months) and years of clinical experience (≥4 years) with chest compression quality during in-hospital cardiac arrest (IHCA).

METHODS

This cohort study of IHCA in four Danish hospitals included cases with data on chest compression quality and team leader characteristics. We assessed the impact of recent simulation training and experienced team leaders on longest chest compression pause duration (primary outcome), chest compression fraction (CCF), and chest compression rates within guideline recommendations using mixed effects models.

RESULTS

Of 157 included resuscitation attempts, 45% had a team leader who recently participated in simulation training and 66% had an experienced team leader. The median team leader experience was 7 years [Q1; Q3: 4; 11]. The median duration of the longest chest compression pause was 16 seconds [10; 30]. Having a team leader with recent simulation training was associated with significantly shorter longest pause durations (difference: -7.11 seconds (95%-CI: -12.0; -2.2), p=0.004), a higher CCF (difference: 3 % (95%-CI: 2.0; 4.0%), p<0.001) and with less guideline compliant chest compression rates (odds ratio: 0.4 (95%-CI: 0.19; 0.84), p=0.02). Having an experienced team leader was not associated with longest pause duration (difference: -1.57 seconds (95%-CI: -5.34; 2.21), p=0.42), CCF (difference: 0.72 % (95%-CI: -0.3; 1.73), p=0.17) or chest compression rates within guideline recommendations (odds ratio: 1.55 (95%-CI: 0.91; 2.66), p=0.11).

CONCLUSION

Recent simulation training of team leaders, but not years of team leader experience, was associated with shorter chest compression pauses during IHCA.

Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest

BACKGROUND

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurologicalal outcomes.

METHODS

In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes.

RESULTS

We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (absolute risk reduction, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (absolute risk reduction, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (absolute risk reduction, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with lower absolute risk reduction of return of spontaneous circulation, but not survival or neurological outcomes.

CONCLUSIONS

Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study

OBJECTIVES

Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]).

DESIGN

Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS).

SETTING

Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020.

PATIENTS

A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822).

CONCLUSIONS

Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.

Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021)

OBJECTIVES

Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients.

DESIGN

Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497).

SETTING

Eighteen ICUs participated in ICU-RESUS.

PATIENTS

There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation.

CONCLUSIONS

We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.

Association of Pediatric Post-Cardiac Arrest Ventilation and Oxygenation with Survival Outcomes

RATIONALE

Adult and pediatric studies provide conflicting data whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia and/or hypocapnia are associated with worse outcomes.

OBJECTIVES

Determine if post-arrest hypoxemia or post-arrest hyperoxemia are associated with lower rates of survival to hospital discharge compared to post-arrest normoxemia, and if post-arrest hypocapnia or hypercapnia are associated with lower rates of survival compared to post-arrest normocapnia.

METHODS

Embedded prospective observational study during a multi-center interventional cardiopulmonary resuscitation trial from 2016-2021. Patients ≤18 years and ≥37 weeks corrected gestational age who received chest compressions for cardiac arrest in one of 18 ICUs were included. Exposures during the first 24 hours post-arrest were hypoxemia, hyperoxemia, or normoxemia defined as lowest PaO2 <60mmHg, highest PaO2 ≥200mmHg, or every PaO2 60-199mmHg, respectively, and hypocapnia, hypercapnia, or normocapnia defined as lowest PaCO2 <30mmHg, highest PaCO2 ≥50mmHg, or every PaCO2 30-49mmHg, respectively. Associations of oxygenation and carbon dioxide group with survival to hospital discharge were assessed using Poisson regression with robust error estimates.

MEASUREMENTS AND MAIN RESULTS

The hypoxemia group was less likely to survive to hospital discharge compared with the normoxemia group (aRR 0.71, 0.58-0.87), whereas the hyperoxemia group survival did not differ from the normoxemia group (aRR 1.0, 0.87-1.15). The hypercapnia group was less likely to survive to hospital discharge compared with the normocapnia group (aRR 0.74, 0.64-0.84), whereas the hypocapnia group survival did not differ from the normocapnia group (aRR 0.91, 0.74-1.12).

CONCLUSIONS

Post-arrest hypoxemia and hypercapnia were each associated with lower rates of survival to hospital discharge.

Adverse Tracheal Intubation Events in Critically Ill Underweight and Obese Children: Retrospective Study of the National Emergency Airway for Children Registry (2013-2020)

OBJECTIVES

Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry oxygen saturation < 80%) in critically ill children.

DESIGN/SETTING

Retrospective cohort using the National Emergency Airway for Children registry dataset of 2013-2020.

PATIENTS

Critically ill children, 0 to 17 years old, undergoing TI in PICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Registry data from 24,342 patients who underwent TI between 2013 and 2020 were analyzed. Patients were categorized using the Centers for Disease Control and Prevention weight-for-age chart: normal weight (5th-84th percentile) 57.1%, underweight (< 5th percentile) 27.5%, overweight (85th to < 95th percentile) 7.2%, and obese (≥ 95th percentile) 8.2%. Underweight was most common in infants (34%); obesity was most common in children older than 8 years old (15.1%). Underweight patients more often had oxygenation and ventilation failure (34.0%, 36.2%, respectively) as the indication for TI and a history of difficult airway (16.7%). Apneic oxygenation was used more often in overweight and obese patients (19.1%, 19.6%) than in underweight or normal weight patients (14.1%, 17.1%; p < 0.001). TIAEs and/or hypoxemia occurred more often in underweight (27.1%) and obese (24.3%) patients ( p < 0.001). TI in underweight children was associated with greater odds of adverse airway outcome compared with normal weight children after adjusting for potential confounders (underweight: adjusted odds ratio [aOR], 1.09; 95% CI, 1.01-1.18; p = 0.016). Both underweight and obesity were associated with hypoxemia after adjusting for covariates and site clustering (underweight: aOR, 1.11; 95% CI, 1.02-1.21; p = 0.01 and obesity: aOR, 1.22; 95% CI, 1.07-1.39; p = 0.002).

CONCLUSIONS

In underweight and obese children compared with normal weight children, procedures around the timing of TI are associated with greater odds of adverse airway events.

A research definition and framework for acute paediatric critical illness across resource-variable settings: a modified Delphi consensus

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We present an evidence-informed consensus definition and framework for acute paediatric critical illness. DEFCRIT was developed following a scoping review of 29 studies and key concepts identified by an interdisciplinary, international core expert panel (n=24). A modified Delphi process was then done with a panel of multidisciplinary health-care global experts (n=109) until consensus was reached on eight essential attributes and 28 statements as the basis of DEFCRIT. Consensus was reached in two Delphi rounds with an expert retention rate of 89%. The final consensus definition for acute paediatric critical illness is: an infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal physiological parameters or vital organ dysfunction or failure) or a clinical support requirement (such as frequent or continuous monitoring or time-sensitive interventions) to prevent further deterioration or death. The proposed definition and framework provide the conceptual clarity needed for a unified approach for global research across resource-variable settings. Future work will centre on validating DEFCRIT and determining high priority measures and guidelines for data collection and analysis that will promote its use in research.

Associations Between End-Tidal Carbon Dioxide During Pediatric Cardiopulmonary Resuscitation, Cardiopulmonary Resuscitation Quality, and Survival

BACKGROUND

Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that "specific values to guide therapy have not been established in children."

METHODS

This prospective observational cohort study was a National Heart, Lung, and Blood Institute-funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO2 data were included. The primary exposure was event-level average ETCO2 during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus <20 mm Hg on the basis of adult literature). The primary outcome was survival to hospital discharge. Secondary outcomes were sustained return of spontaneous circulation, survival to discharge with favorable neurological outcome, and new morbidity among survivors. Poisson regression measured associations between ETCO2 and outcomes as well as the association between ETCO2 and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate).

RESULTS

Among 234 included patients, 133 (57%) had an event-level average ETCO2 ≥20 mm Hg. After controlling for a priori covariates, average ETCO2 ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04-1.69]; P=0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00-1.49]; P=0.046) compared with lower values. ETCO2 ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average 2 ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO2 groups.

CONCLUSIONS

In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO2 ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.

Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis

AIM

Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes.

METHODS AND RESULTS

Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes.

CONCLUSIONS

Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.

Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease

OBJECTIVES

To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease.

DESIGN

Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021).

SETTING

Eighteen PICUs.

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups.

CONCLUSIONS

In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.

Trends in community response and long-term outcomes from pediatric cardiac arrest: A retrospective observational study

AIM

This study aimed to investigate trends over time in pre-hospital factors for pediatric out-of-hospital cardiac arrest (pOHCA) and long-term neurological and neuropsychological outcomes. These have not been described before in large populations.

METHODS

Non-traumatic arrest patients, 1 day-17 years old, presented to the Sophia Children's Hospital from January 2002 to December 2020, were eligible for inclusion. Favorable neurological outcome was defined as Pediatric Cerebral Performance Categories (PCPC) 1-2 or no difference with pre-arrest baseline. The trend over time was tested with multivariable logistic and linear regression models with year of event as independent variable.

FINDINGS

Over a nineteen-year study period, the annual rate of long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, increased significantly (OR 1.10, 95%-CI 1.03-1.19), adjusted for confounders. Concurrently, annual automated external defibrillator (AED) use and, among adolescents, initial shockable rhythm increased significantly (OR 1.21, 95% CI 1.10-1.33 and OR 1.15, 95% CI 1.02-1.29, respectively), adjusted for confounders. For generalizability purposes, only the total intelligence quotient (IQ) was considered for trend analysis of all tested domains. Total IQ scores and bystander basic life support (BLS) rate did not change significantly over time.

INTERPRETATION

Long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, improved significantly over the study period. Total IQ scores did not significantly change over time. Furthermore, AED use (OR 1.21, 95%CI 1.10-1.33) and shockable rhythms among adolescents (OR1.15, 95%CI 1.02-1.29) increased over time.

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BACKGROUND

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

METHODS

A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice.

RESULTS

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

CONCLUSIONS

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Whole blood transcriptomics identifies subclasses of pediatric septic shock

BACKGROUND

Sepsis is a highly heterogeneous syndrome, which has hindered the development of effective therapies. This has prompted investigators to develop a precision medicine approach aimed at identifying biologically homogenous subgroups of patients with septic shock and critical illnesses. Transcriptomic analysis can identify subclasses derived from differences in underlying pathophysiological processes that may provide the basis for new targeted therapies. The goal of this study was to elucidate pathophysiological pathways and identify pediatric septic shock subclasses based on whole blood RNA expression profiles.

METHODS

The subjects were critically ill children with cardiopulmonary failure who were a part of a prospective randomized insulin titration trial to treat hyperglycemia. Genome-wide expression profiling was conducted using RNA sequencing from whole blood samples obtained from 46 children with septic shock and 52 mechanically ventilated noninfected controls without shock. Patients with septic shock were allocated to subclasses based on hierarchical clustering of gene expression profiles, and we then compared clinical characteristics, plasma inflammatory markers, cell compositions using GEDIT, and immune repertoires using Imrep between the two subclasses.

RESULTS

Patients with septic shock depicted alterations in innate and adaptive immune pathways. Among patients with septic shock, we identified two subtypes based on gene expression patterns. Compared with Subclass 2, Subclass 1 was characterized by upregulation of innate immunity pathways and downregulation of adaptive immunity pathways. Subclass 1 had significantly worse clinical outcomes despite the two classes having similar illness severity on initial clinical presentation. Subclass 1 had elevated levels of plasma inflammatory cytokines and endothelial injury biomarkers and demonstrated decreased percentages of CD4 T cells and B cells and less diverse T cell receptor repertoires.

CONCLUSIONS

Two subclasses of pediatric septic shock patients were discovered through genome-wide expression profiling based on whole blood RNA sequencing with major biological and clinical differences. Trial Registration This is a secondary analysis of data generated as part of the observational CAF-PINT ancillary of the HALF-PINT study (NCT01565941). Registered March 29, 2012.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia

Background

Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils.

Methods

Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023.

Results

While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest.

Conclusion

This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial

OBJECTIVE

To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock.

DESIGN

Parallel-group, blinded multicenter trial.

SETTING

PICUs of four tertiary care centers in India from 2017 to 2020.

PATIENTS

Children up to 15 years of age with septic shock.

METHODS

Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality.

INTERVENTIONS

MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days.

MEASUREMENTS AND MAIN RESULTS

The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups.

CONCLUSIONS

Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

INTRODUCTION

Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

METHODS

We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

RESULTS

Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

CONCLUSIONS

Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.

Association of CPR simulation program characteristics with simulated and actual performance during paediatric in-hospital cardiac arrest

AIM

To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest.

METHODS

This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a prospective, multicentre cluster randomized interventional trial conducted in 18 ICUs from October 2016-March 2021. Point-of-care bedside simulations with real-time feedback to allow multidisciplinary ICU staff to practice CPR on a portable manikin were performed and quality metrics (rate, depth, release velocity, chest compression fraction) were recorded. Actual CPR performance was recorded for children 37 weeks post-conceptual age to 18 years who received chest compressions of any duration, and included intra-arrest haemodynamics and CPR mechanics. Outcomes included survival to hospital discharge with favourable neurologic status.

RESULTS

Overall, 18,912 point-of-care simulations were included. Simulation characteristics associated with both simulation and actual performance included site, participant discipline, and timing of simulation training. Simulation characteristics were not associated with survival with favourable neurologic outcome. However, participants in the top 3 sites for improvement in survival with favourable neurologic outcome were more likely to have participated in a simulation in the past month, on a weekday day, to be nurses, and to achieve targeted depth of compression and chest compression fraction goals during simulations than the bottom 3 sites.

CONCLUSIONS

Point-of-care simulation characteristics were associated with both simulated and actual CPR performance. More recent simulation, increased nursing participation, and simulation training during daytime hours may improve CPR performance.

Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial

BACKGROUND

Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes.

METHODS

This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR.

RESULTS

Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups.

CONCLUSIONS

In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.

Whole Blood Transcriptomics Identifies Subclasses of Pediatric Septic Shock

Background

Sepsis is a highly heterogeneous syndrome, that has hindered the development of effective therapies. This has prompted investigators to develop a precision medicine approach aimed at identifying biologically homogenous subgroups of patients with septic shock and critical illnesses. Transcriptomic analysis can identify subclasses derived from differences in underlying pathophysiological processes that may provide the basis for new targeted therapies. The goal of this study was to elucidate pathophysiological pathways and identify pediatric septic shock subclasses based on whole blood RNA expression profiles.

Methods

The subjects were critically ill children with cardiopulmonary failure who were a part of a prospective randomized insulin titration trial to treat hyperglycemia. Genome-wide expression profiling was conducted using RNA-sequencing from whole blood samples obtained from 46 children with septic shock and 52 mechanically ventilated noninfected controls without shock. Patients with septic shock were allocated to subclasses based on hierarchical clustering of gene expression profiles, and we then compared clinical characteristics, plasma inflammatory markers, cell compositions using GEDIT, and immune repertoires using Imrep between the two subclasses.

Results

Patients with septic shock depicted alterations in innate and adaptive immune pathways. Among patients with septic shock, we identified two subtypes based on gene expression patterns. Compared with Subclass 2, Subclass 1 was characterized by upregulation of innate immunity pathways and downregulation of adaptive immunity pathways. Subclass 1 had significantly worse clinical outcomes despite the two classes having similar illness severity on initial clinical presentation. Subclass 1 had elevated levels of plasma inflammatory cytokines and endothelial injury biomarkers and demonstrated decreased percentages of CD4 T cells and B cells, and less diverse T-Cell receptor repertoires.

Conclusions

Two subclasses of pediatric septic shock patients were discovered through genome-wide expression profiling based on whole blood RNA sequencing with major biological and clinical differences.

Trial Registration

This is a secondary analysis of data generated as part of the observational CAF PINT ancillary of the HALF PINT study (NCT01565941). Registered 29 March 2012.

Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA).

DESIGN

Retrospective cohort study.

SETTING

An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q].

PATIENTS

All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100-149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately.

CONCLUSIONS

The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.

Poor Concordance of One-Third Anterior-Posterior Chest Diameter Measurements With Absolute Age-Specific Chest Compression Depth Targets in Pediatric Cardiac Arrest Patients

Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one-third anterior-posterior diameter (APD), which is presumed to equate to absolute age-specific chest compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumption. We aimed to study the concordance of measured one-third APD with absolute age-specific chest compression depth targets in a cohort of pediatric patients with cardiac arrest. Methods and Results This was a retrospective observational study from a multicenter, pediatric resuscitation quality collaborative (pediRES-Q [Pediatric Resuscitation Quality Collaborative]) from October 2015 to March 2022. In-hospital patients with cardiac arrest ≤12 years old with APD measurements recorded were included for analysis. One hundred eighty-two patients (118 infants >28 days old to <1 year old, and 64 children 1 to 12 years old) were analyzed. The mean one-third APD of infants was 3.2 cm (SD, 0.7 cm), which was significantly smaller than the 4 cm target depth (P<0.001). Seventeen percent of the infants had one-third APD measurements within the 4 cm ±10% target range. For children, the mean one-third APD was 4.3 cm (SD, 1.1 cm). Thirty-nine percent of children had one-third APD within the 5 cm ±10% range. Except for children 8 to 12 years old and overweight children, the measured mean one-third APD of the majority of the children was significantly smaller than the 5 cm depth target (P<0.05). Conclusions There was poor concordance between measured one-third APD and absolute age-specific chest compression depth targets, particularly for infants. Further study is needed to validate current pediatric chest compression depth targets and evaluate the optimal chest compression depth to improve cardiac arrest outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.

Adaptation of a Simulation Model and Checklist to Assess Pediatric Emergency Care Performance by Prehospital Teams

INTRODUCTION

Simulation tools to assess prehospital team performance and identify patient safety events are lacking. We adapted a simulation model and checklist tool of individual paramedic performance to assess prehospital team performance and tested interrater reliability.

METHODS

We used a modified Delphi process to adapt 3 simulation cases (cardiopulmonary arrest, seizure, asthma) and checklist to add remote physician direction, target infants, and evaluate teams of 2 paramedics and 1 physician. Team performance was assessed with a checklist of steps scored as complete/incomplete by raters using direct observation or video review. The composite performance score was the percentage of completed steps. Interrater percent agreement was compared with the original tool. The tool was modified, and raters trained in iterative rounds until composite performance scoring agreement was 0.80 or greater (scale <0.20 = poor; 0.21-0.39 = fair, 0.40-0.59 = moderate; 0.60-0.79 = good; 0.80-1.00 = very good).

RESULTS

We achieved very good interrater agreement for scoring composite performance in 2 rounds using 6 prehospital teams and 4 raters. The original 175 step tool was modified to 171 steps. Interrater percent agreement for the final modified tool approximated the original tool for the composite checklist (0.80 vs. 0.85), cardiopulmonary arrest (0.82 vs. 0.86), and asthma cases (0.80 vs. 0.77) but was lower for the seizure case (0.76 vs. 0.91). Most checklist items (137/171, 80%) had good-very good agreement. Among 34 items with fair-moderate agreement, 15 (44%) related to patient assessment, 9 (26%) equipment use, 6 (18%) medication delivery, and 4 (12%) cardiopulmonary resuscitation quality.

CONCLUSIONS

The modified checklist has very good agreement for assessing composite prehospital team performance and can be used to test effects of patient safety interventions.

Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes

AIM

To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit.

METHODS

This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses.

RESULTS

Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency.

CONCLUSIONS

Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.

The physiologic response to epinephrine and pediatric cardiopulmonary resuscitation outcomes

BACKGROUND

Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not been well described. Thus, the objective of this study was to measure the association between change in DBP after epinephrine administration during CPR and ROSC.

METHODS

This was a prospective multicenter study of children receiving ≥ 1 min of CPR with ≥ 1 dose of epinephrine and evaluable invasive arterial BP data in the 18 ICUs of the ICU-RESUS trial (NCT02837497). Blood pressure waveforms underwent compression-by-compression quantitative analysis. The mean DBP before first epinephrine dose was compared to mean DBP two minutes post-epinephrine. Patients with ≥ 5 mmHg increase in DBP were characterized as "responders."

RESULTS

Among 147 patients meeting inclusion criteria, 66 (45%) were characterized as responders and 81 (55%) were non-responders. The mean increase in DBP with epinephrine was 4.4 [- 1.9, 11.5] mmHg (responders: 13.6 [7.5, 29.3] mmHg versus non-responders: - 1.5 [- 5.0, 1.5] mmHg; p < 0.001). After controlling for a priori selected covariates, epinephrine response was associated with ROSC (aRR 1.60 [1.21, 2.12]; p = 0.001). Sensitivity analyses identified similar associations between DBP response thresholds of ≥ 10, 15, and 20 mmHg and ROSC; DBP responses of ≥ 10 and ≥ 15 mmHg were associated with higher aRR of survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category score of 1-3 or no worsening from baseline).

CONCLUSIONS

The change in DBP following epinephrine administration during pediatric in-hospital CPR was associated with return of spontaneous circulation.

Active Bleeding Control - Can Pediatricians Stem the Tide of Lives Lost from Trauma Through 'Stop the Bleed' Training?

Trauma is a global challenge and India has one of the highest trauma deaths in the world. Despite United Nations target to halve the global number of deaths and injuries from road traffic crashes by 2030, death tolls from Road Traffic Injuries (RTI) rising in India. In pediatric age groups, falls from height add to the burden of trauma. Uncontrolled bleeding from exsanguination on scene is estimated to account for nearly 40% of RTI trauma related mortality. Stopping the bleeding in the first few minutes is crucial for meaningful survival and hence the role of training lay public who can reach the scene in minutes. Active Bleeding Control (ABC) pilot research project to simulation train the bystanders to stop the bleed showed promising outcomes in Hyderabad, India. This paper describes the ABC project and discusses the role of pediatricians in training the public to reduce morbidity and mortality from uncontrolled bleeding at trauma scene.

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)

OBJECTIVES

We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed.

DESIGN

International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science.

SETTING

Not applicable.

PATIENTS

Patients with or at risk for PARDS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%.

CONCLUSIONS

PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.

Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children

Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p< 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.

Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study

OBJECTIVES

Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort.

DESIGN

Prospective observational study.

SETTING

Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020.

PATIENTS

Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051).

CONCLUSIONS

These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.

Comparison of Bedside and Video-Based Capillary Refill Time Assessment in Children

OBJECTIVES

Capillary refill time (CRT) to assess peripheral perfusion in children with suspected shock may be subject to poor reproducibility. Our objectives were to compare video-based and bedside CRT assessment using a standardized protocol and evaluate interrater and intrarater consistency of video-based CRT (VB-CRT) assessment. We hypothesized that measurement errors associated with raters would be low for both standardized bedside CRT and VB-CRT as well as VB-CRT across raters.

METHODS

Ninety-nine children (aged 1-12 y) had 5 consecutive bedside CRT assessments by an experienced critical care clinician following a standardized protocol. Each CRT assessment was video recorded on a black background. Thirty video clips (10 with bedside CRT < 1 s, 10 with CRT 1-2 s, and 10 with CRT > 2 s) were randomly selected and presented to 10 clinicians twice in randomized order. They were instructed to push a button when they visualized release of compression and completion of a capillary refill. The correlation and absolute difference between bedside and VB-CRT were assessed. Consistency across raters and within each rater was analyzed using the intraclass correlation coefficient (ICC). A Generalizability study was performed to evaluate sources of variation.

RESULTS

We found moderate agreement between bedside and VB-CRT observations (r = 0.65; P < 0.001). The VB-CRT values were shorter by 0.17 s (95% confidence interval, 0.09-0.25; P < 0.001) on average compared with bedside CRT. There was moderate agreement in VB-CRT across raters (ICC = 0.61). Consistency of repeated VB-CRT within each rater was moderate (ICC = 0.71). Generalizability study revealed the source of largest variance was from individual patient video clips (57%), followed by interaction of the VB-CRT reviewer and patient video clip (10.7%).

CONCLUSIONS

Bedside and VB-CRT observations showed moderate consistency. Using video-based assessment, moderate consistency was also observed across raters and within each rater. Further investigation to standardize and automate CRT measurement is warranted.

Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey

OBJECTIVES

Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown.

DESIGN

Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test.

SETTING

Internet-based survey.

SUBJECTS

U.S. PICU representatives (one per institution) involved in resuscitation systems of care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02).

CONCLUSIONS

The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.

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

OBJECTIVES

To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA).

DESIGN

Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial.

SETTING

Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497).

PATIENTS

Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621).

CONCLUSIONS

In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.

A prospective observational study of video laryngoscopy-guided coaching in the pediatric intensive care unit

BACKGROUND

There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room.

AIM

Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation-associated events.

METHODS

This is a pre-post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single-center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation-associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured.

RESULTS

Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation-associated events between the two phases (pre- 9% vs. post- 5%, absolute difference -3%, CI95 : -8% to 1%, p = .11), oxygen desaturations <80% (pre- 13% vs. post- 13%, absolute difference 1%, CI95 : -6% to 5%, p = .75), or first attempt success (pre- 73% vs. post- 76%, absolute difference 4%, CI95 : -3% to 11%, p = .29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95 : 23% to 51%, p < .001).

CONCLUSIONS

Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation-associated events and oxygen desaturation.

Be Prepared: A Pediatric Simulation Center's Early Pandemic Contributions

INTRODUCTION

The COVID-19 pandemic forced healthcare institutions to rapidly adapt practices for patient care, staff safety, and resource management. We evaluated contributions of the simulation center in a freestanding children's hospital during the early stages of the pandemic.

METHODS

We reviewed our simulation center's activity for education-based and system-focused simulation for 2 consecutive academic years (AY19: 2018-2019 and AY20: 2019-2020). We used statistical control charts and χ 2 analyses to assess the impact of the pandemic on simulation activity as well as outputs of system-focused simulation during the first wave of the pandemic (March-June 2020) using the system failure mode taxonomy and required level of resolution.

RESULTS

A total of 1983 event counts were reported. Total counts were similar between years (994 in AY19 and 989 in AY20). System-focused simulation was more prevalent in AY20 compared with AY19 (8% vs. 2% of total simulation activity, P < 0.001), mainly driven by COVID-19-related simulation events. COVID-19-related simulation occurred across the institution, identified system failure modes in all categories except culture, and was more likely to identify macro-level issues than non-COVID-19-related simulation (64% vs. 44%, P = 0.027).

CONCLUSIONS

Our simulation center pivoted to deliver substantial system-focused simulation across the hospital during the first wave of the COVID-19 pandemic. Our experience suggests that simulation centers are essential resources in achieving safe and effective hospital-wide improvement.

Outcomes Associated With Timing of Neurologic Dysfunction Onset Relative to Pediatric Sepsis Recognition

OBJECTIVES

To compare outcomes associated with timing-early versus late-of any neurologic dysfunction during pediatric sepsis.

DESIGN

Secondary analysis of a cross-sectional point prevalence study.

SETTING

A total of 128 PICUs in 26 countries.

PATIENTS

Less than 18 years with severe sepsis on 5 separate days (2013-2014).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized as having either no neurologic dysfunction or neurologic dysfunction (i.e., present at or after sepsis recognition), which was defined as Glasgow Coma Scale score less than 5 and/or fixed dilated pupils. Our primary outcome was death or new moderate disability (i.e., Pediatric Overall [or Cerebral] Performance Category score ≥3 and change ≥1 from baseline) at hospital discharge, and 87 of 567 severe sepsis patients (15%) had neurologic dysfunction within 7 days of sepsis recognition (61 at sepsis recognition and 26 after sepsis recognition). Primary site of infection varied based on presence of neurologic dysfunction. Death or new moderate disability occurred in 161 of 480 (34%) without neurologic dysfunction, 45 of 61 (74%) with neurologic dysfunction at sepsis recognition, and 21 of 26 (81%) with neurologic dysfunction after sepsis recognition (p < 0.001 across all groups). On multivariable analysis, in comparison with those without neurologic dysfunction, neurologic dysfunction whether at sepsis recognition or after was associated with increased odds of death or new moderate disability (adjusted odds ratio, 4.9 [95% CI, 2.3-10.1] and 10.7 [95% CI, 3.8-30.5], respectively). We failed to identify a difference between these adjusted odds ratios of death or new moderate disability that would indicate a differential risk of outcome based on timing of neurologic dysfunction (p = 0.20).

CONCLUSIONS

In this severe sepsis international cohort, the presence of neurologic dysfunction during sepsis is associated with worse outcomes at hospital discharge. The impact of early versus late onset of neurologic dysfunction in sepsis on outcome remains unknown, and further work is needed to better understand timing of neurologic dysfunction onset in pediatric sepsis.

Transcriptome and metabolome after porcine hemodynamic-directed CPR compared with standard CPR and sham controls

Objective

The effect of cardiac arrest (CA) on cerebral transcriptomics and metabolomics is unknown. We previously demonstrated hemodynamic-directed CPR (HD-CPR) improves survival with favorable neurologic outcomes versus standard CPR (Std-CPR). We hypothesized HD-CPR would preserve the cerebral transcriptome and metabolome compared to Std-CPR.

Design

Randomized pre-clinical animal trial.

Setting

Large animal resuscitation laboratory at an academic children’s hospital.

Subjects

Four-week-old female piglets (8–11 kg).

Interventions

Pigs (1-month-old), three groups: 1) HD-CPR (compression depth to systolic BP 90 mmHg, vasopressors to coronary perfusion pressure 20 mmHg); 2) Std-CPR and 3) shams (no CPR). HD-CPR and Std-CPR underwent asphyxia, induced ventricular fibrillation, 10–20 min of CPR and post-resuscitation care. Primary outcomes at 24 h in cerebral cortex: 1) transcriptomic analysis (n = 4 per treatment arm, n = 8 sham) of 1727 genes using differential gene expression and 2) metabolomic analysis (n = 5 per group) of 27 metabolites using one-way ANOVA, post-hoc Tukey HSD.

Measurements and main results

65 genes were differentially expressed between HD-CPR and Std-CPR and 72 genes between Std-CPR and sham, but only five differed between HD-CPR and sham. Std-CPR increased the concentration of five AA compared to HD-CPR and sham, including the branched chain amino acids (BCAA), but zero metabolites differed between HD-CPR and sham.

Conclusions

In cerebral cortex 24 h post CA, Std-CPR resulted in a different transcriptome and metabolome compared with either HD-CPR or sham. HD-CPR preserves the transcriptome and metabolome, and is neuroprotective. Global molecular analyses may be a novel method to assess efficacy of clinical interventions and identify therapeutic targets.

Institutional protocol number

IAC 16-001023.

Impact of different methods to activate the pediatric mode in automated external defibrillators by laypersons - A randomized controlled simulation study

Introduction

Defibrillation with automated external defibrillators (AEDs) for smaller children with out-of-hospital cardiac arrest (OHCA) should be performed using a pediatric mode. This study aims to investigate the easiest and fastest way to activate the pediatric mode on AEDs for pediatric OHCA.

Methods

This randomized, controlled simulation study recruited 90 adult laypersons. Laypersons were randomized to use one of three AEDs with different methods to activate the pediatric mode: a Lifepak CR-T Trainer requiring switch of electrodes, a Phillips Heartstart FR3 Trainer with a "pediatric key", or a CU Medical IPAD SP1 Trainer with a pediatric button. Laypersons were asked to use an AED on a pediatric manikin and informed that activation of a pediatric mode was recommended.

Results

Activation of the pediatric mode was achieved by 0/30 (0%) participants when switching electrodes (Lifepak CRT), 2/30 (7%) participants when using a key (Phillips FR3) and 18/30 (64%) participants when pushing a button (CU Medical SP1) (p < 0.001). The median (interquartile range) time to first shock among those who activated the pediatric mode were 102 (95-107) in the CU Medical SP1 group and 78 (78-78) in the Phillips FR3 group (p = 0.21). Most participants used the anterior-lateral position for electrodes.

Conclusion

Laypersons' ability to activate the pediatric mode on AEDs and correctly attach the electrodes was generally poor. More participants were able to activate the pediatric mode by pushing a button when compared to using a key or switching electrodes. Use of the Phillips FR3 AED was associated with faster shock delivery.

Association of Chest Compression Pause Duration Prior to E-CPR Cannulation with Cardiac Arrest Survival Outcomes

OBJECTIVE

To characterize chest compression (CC) pause duration during the last 5 minutes of pediatric cardiopulmonary resuscitation (CPR) prior to extracorporeal-CPR (E-CPR) cannulation and the association with survival outcomes.

METHODS

Cohort study from a resuscitation quality collaborative including pediatric E-CPR cardiac arrest events ≥10 min with CPR quality data. We characterized CC interruptions during the last 5 min of defibrillator-electrode recorded CPR (prior to cannulation) and assessed the association between the longest CC pause duration and survival outcomes using multivariable logistic regression.

RESULTS

Of 49 E-CPR events, median age was 2.0 [Q1, Q3: 0.6, 6.6] years, 55% (27/49) survived to hospital discharge and 18/49 (37%) with favorable neurological outcome. Median duration of CPR was 51 [43, 69] min. During the last 5 min of recorded CPR prior to cannulation, median duration of the longest CC pause was 14.0 [6.3, 29.4] sec: 66% >10 sec, 25% >29 sec, 14% >60 sec, and longest pause 168 sec. Following planned adjustment for known confounders of age and CPR duration, each 5-sec increase in longest CC pause duration was associated with lower odds of survival to hospital discharge [adjusted OR 0.89, 95%CI: 0.79-0.99] and lower odds of survival with favorable neurological outcome [adjusted OR 0.77, 95%CI: 0.60-0.98].

CONCLUSIONS

Long CC pauses were common during the last 5 min of recorded CPR prior to E-CPR cannulation. Following adjustment for age and CPR duration, each 5-second incremental increase in longest CC pause duration was associated with significantly decreased rates of survival and favorable neurological outcome.

Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial

IMPORTANCE

Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes.

OBJECTIVE

To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings.

DESIGN, SETTING, AND PARTICIPANTS

A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021).

INTERVENTION

During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge.

RESULTS

Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02837497.

Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: a prospective, observational study

AIM

Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge.

METHODS

Prospective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge.

RESULTS

Twenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge.

CONCLUSIONS

Higher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.

Low-Cost "Telesimulation" Training Improves Real Patient Pediatric Shock Outcomes in India

INTRODUCTION

Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COVID-19 pandemic restrictions on in-person simulation led us to the development of telesimulation for shock. We hypothesized that telesimulation training would improve pediatric shock recognition, process of care, and patient outcomes in both simulated and real patient settings.

MATERIALS AND METHODS

We conducted a prospective quasi-experimental interrupted time series cohort study over 9 months. We conducted 40 telesimulation sessions for 76 participants in teams of 3 or 4, utilizing the video telecommunication platform (Zoom©). Trained observers recorded time-critical interventions on real patients for the pediatric emergency teams composed of residents, fellows, and nurses. Data were collected on 332 pediatric patients in shock (72% of whom were in septic shock) before, during, and after the intervention. The data included the first hour time-critical intervention checklist, patient hemodynamic status at the end of the first hour, time for the resolution of shock, and team leadership skills in the emergency room.

RESULTS

There was a significant improvement in the percent completion of tasks by the pediatric emergency team in simulated scenarios (69% in scenario 1 vs. 93% in scenario 2; p < 0.001). In real patients, completion of tasks as per time-critical steps reached 100% during and after intervention compared to the pre-intervention phase (87.5%), p < 0.05. There was a significant improvement in the first hour hemodynamic parameters of shock patients: pre (71%), during (79%), and post (87%) intervention (p < 0.007 pre vs. post). Shock reversal time reduced from 24 h pre-intervention to 6 h intervention and to 4.5 h post intervention (p < 0.002). There was also a significant improvement in leadership performance assessed by modified Concise Assessment of Leader Management (CALM) instrument during the simulated (p < 0.001) and real patient care in post intervention (p < 0.05).

CONCLUSION

Telesimulation training is feasible and improved the process of care, time-critical interventions, leadership in both simulated and real patients and resolution of shock in real patients. To the best of our knowledge, this is one of the first studies where telesimulation has shown improvement in real patient outcomes.

Breaking barriers in establishing simulation in India-A collaborative approach by pediatric simulation training and research society (PediSTARS)

Simulation based training (SBT) plays a pivotal role in quality improvement and patient safety. Simulation is not only for training health care professionals but also an excellent tool for systems and facility changes which will potentially improve patient safety and ultimately outcomes. SBT is already established both as a training modality, and as a quality improvement tool in high income countries. It's use in low and middle-income countries (LMIC), including India, however, is sporadic and variable because of multiple barriers. The barriers for establishment of simulation are lack of knowledge about benefits of simulation, psychological resistance, cost, and lack of trained faculty. PediSTARS (Pediatric Simulation Training and Research Society), a simulation society was founded in August 2013 to spread the simulation across India and thus improve the quality and safety of health care using SBT. In this article we discuss various barriers for healthcare simulation in India and also our attempts to overcome some of these barriers by collaborative practice.

Pilot Paramedic Survey of Benefits, Risks, and Strategies for Pediatric Prehospital Telemedicine

OBJECTIVE

A national survey found prehospital telemedicine had potential clinical applications but lacked provider opinion on its use for pediatric emergency care. We aimed to (1) estimate prehospital telemedicine use, (2) describe perceived benefits and risks of pediatric applications, and (3) identify preferred utilization strategies by paramedics.

METHODS

We administered a 14-question survey to a convenience sample of 25 Massachusetts paramedics attending a regional course in 2018. Volunteer participants were offered a gift card. We compared respondents to a state database for sample representativeness. We present descriptive statistics and summarize qualitative responses.

RESULTS

Twenty-five paramedics completed the survey (100% response); 23 (96%) were male, 21 (84%) 40 years or older, and 23 (92%) in urban practice. Respondents were older and more experienced than the average Massachusetts paramedic. Few had used prehospital telemedicine for patients younger than 12 years (8%; 95% confidence interval, 10-26%). Potential benefits included paramedic training (80%), real-time critical care support (68%), risk mitigation (68%), patient documentation (72%), decision support for hospital team activation (68%), and scene visualization (76%). Time delays from telemedicine equipment use (76%) and physician consultation (64%), broadband reliability (52%), and cost (56%) were potential risks. Respondents preferred video strategies for scene visualization, physician-assisted assessment and care. More respondents felt pediatric telemedicine applications would benefit rural/suburban settings than urban ones.

CONCLUSIONS

Paramedics reported prehospital telemedicine is underutilized for children but identified potential benefits including provider telesupport, training, situational awareness, and documentation. Concerns included transportation delays, cost, and broadband availability. Video was preferred for limited pediatric exposure settings. These results inform which telemedicine applications and strategies paramedics favor for children.