No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
In-hospital Pediatric Cardiac Arrest in Honduras
Abstract
The objective of this study was to analyze the characteristic and the prognostic factors of in-hospital pediatric cardiac arrest (CA) in a public hospital Honduras.
A prospective observational study was performed on pediatric in-hospital CA as a part of a multicenter international study. One hundred forty-six children were studied. The primary end point was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality.
Cardiac arrest occurred in the emergency department in 66.9%. Respiratory diseases and sepsis were predominant causes of CA. Return of spontaneous circulation was achieved in 60% of patients, and 22.6% survived to hospital discharge. The factors related with mortality were nonrespiratory cause of CA (odds ratio [OR], 2.55; P = 0.045), adrenaline administration (OR, 4.96; P = 0.008), and a duration of cardiopulmonary resuscitation more than 10 minutes (OR, 3.40; P = 0.012).
In-hospital CA in children in a developing country has low survival. Patients with nonrespiratory causes and those who need adrenaline administration and prolonged resuscitation had worse prognosis.
... Ngoài ra, nguyên nhân gây ngừng tuần hoàn ở trẻ em chủ yếu là thiếu oxy nên đặt nội khí quản kiểm soát đường thở sớm sẽ cung cấp oxy hiệu quả hơn cho bệnh nhân [6]. Trong khi đó, theo nghiên cứu của tác giả Matamoros, không có sự khác biệt có ý nghĩa thống kê về tỉ lệ tử vong giữa 2 nhóm có hay không có can thiệp như mắc monitor, thở máy hoặc dùng thuốc vận mạch [7]. ...
... Vì thế, tỉ lệ tử vong trong nghiên cứu này cao hơn so với các nghiên cứu khác vì tác giả cũng cho rằng thời gian phát hiện ngừng tuần hoàn cũng như tiến hành CPR sớm là rất quan trọng. Đây cũng là lý do mà các hình ảnh điện tâm đồ trong nghiên cứu chủ yếu là vô tâm thu (81,5%) trong khi đó nhịp chậm rất ít (13,9%) [7]. Theo Lopez và cộng sự (năm 2014), việc phát hiện ngừng tuần hoàn ở giai đoạn nhịp tim chậm là rất quan trọng vì đây là dấu hiệu sớm của ngừng tuần hoàn nên nếu CPR được tiến hành sớm sẽ làm tăng khả năng có tim trở lại và hạn chế được di chứng [1]. ...
... Cụ thể, tỉ lệ sống khi ra viện cao nhất ở nhóm cấp cứu ngừng tuần hoàn ≤ 10 phút và thấp nhất ở nhóm cấp cứu > 30 phút, với sự khác biệt không có ý nghĩa thống kê (p >0,05) (Bảng 4). Các nghiên cứu của tác giả Matamoros và Lopez (2014) cũng đưa ra nhận định tương tự khi cho thấy tỉ lệ tử vong cao hơn khi sử dụng Adrenalin từ 3 liều trở lên hoặc sử dụng Bicacbonat cùng với thời gian CPR kéo dài [1], [7]. Mặc dù adrenalin là thuốc vận mạch chủ yếu và quan trọng nhất dùng trong cấp cứu ngừng tuần hoàn tuy nhiên theo tác giả Lopez, những bệnh nhân có chỉ định dùng nhiều lần Adrenalin và cũng như sử dụng Bicacbonat đều là tình trạng bệnh nặng vì thế có tiên lượng xấu hơn và nguy cơ tử vong cao. ...
Mục tiêu: Tìm hiểu một số yếu tố liên quan đến kết quả cấp cứu ngừng tuần hoàn ở trẻ em. Đối tượng và phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang trên 102 trẻ ngừng tuần hoàn tại Bệnh viện Nhi Trung ương từ tháng 6/2018 đến tháng 6/2019. Kết quả: Tỉ lệ cấp cứu thành công (có tim trở lại) ở nhóm đã được mắc monitor theo dõi cao hơn so với nhóm chưa được mắc monitor (70,1% và 33,3%), (p<0,05). Tỉ lệ cấp cứu thành công ở nhóm chưa được sử dụng thuốc vận mạch cao hơn so với nhóm đã dùng thuốc vận mạch (67,7% và 61,5%) và nhóm đã được đặt nội khí quản cao hơn so với nhóm chưa đặt nội khí quản (65,6%và 63,2%) nhưng sự khác biệt không có ý nghĩa thống kê (p>0,05).Tỉ lệ tử vong cao nhất ở nhóm nhịp chậm (91,7%) và thấp nhất ở nhóm vô tâm thu(52,3%), (p<0,05). Tỉ lệ sống khi ra viện ở nhóm tiêm Adrenalin tĩnh mạch ≤3 liều cao hơn so với tiêm Adrenalin tĩnh mạch >3liều (100% và 46,3%). Tỉ lệ sống ra viện cao nhất ở nhóm cấp cứu ngừng tuần hoàn ≤10 phút và thấp nhất ở nhóm cấp cứu >30 phút, (p<0,05). Khi phân tích đa biến, sử dụng Adrenalin tĩnh mạch và thời gian cấp cứu ngừng tuần hoàn là các yếu tố liên quan đến hiệu quả cấp cứu ngừng tuần hoàn (p<0,05). Kết luận: thời gian cấp cứu ngừng tuần hoàn, sử dụng Adrenalin tĩnh mạch là những yếu liên quan đến hiệu quả cấp cứu ngừng tuần hoàn.
... Trong số 102 bệnh nhân nghiên cứu, tỉ lệ trẻ nam và nữ chiếm tỉ lệ lần lượt là 51% và 49% và không có sự khác biệt giữa 2 giới (Bảng 1). Nghiên cứu của Matamoros và cộng sự cũng đưa ra nhận định tương tự khi cho thấy không có sự khác biệt về giới tính của các trẻ ngừng tuần hoàn [6]. Về phân bố nhóm tuổi, nhóm dưới 1 tuổi chiếm tỉ lệ cao nhất (43,1%) (Bảng 1). ...
... Điều này lý giải vì sao tỉ lệ ngừng tuần hoàn xảy ra tại khoa cấp cứu chiếm tỉ lệ cao nhất đặc biệt là ngừng tuần hoàn ngoại viện. Nghiên cứu của Maramotos và cộng sự cũng đưa ra kết quả tương tự khi cho thấy ngừng tuần hoàn xảy ra chủ yếu ở khoa cấp cứu (66,9%), tiếp theo là khoa hồi sức cấp cứu (21,3%) [6]. ...
... Tác giả Matamoros và cộng sự đã tiến hành nghiên cứu hồi cứu trên 146 bệnh nhân có độ tuổi từ 1 tháng đến 18 tuổi ở Honduras tuổi được chẩn đoán ngừng tuần hoàn nội viện từ năm 2007 đến năm2009. Kết quả cho thấy, nguyên nhân gây ngừng tuần hoàn thường gặp nhất là hô hấp (34,2%), tiếp theo là do nhiễm khuẩn (33,5%), sau đó là nguyên nhân timmạch và các bệnh về thần kinh (đều là 11,6%) [6]. Tuy nhiên, nghiên cứu của Matamoros là về ngừng tuần hoàn nội viện nên có thể các bệnh lý gây ngừng tuần hoàn khác so với chúng tôi. ...
Mục tiêu: Mô tả đặc điểm dịch tễ học lâm sàng ngừng tuần hoàn ở trẻ em tại Bệnh viện Nhi Trung ương từ tháng 6/2018 đến tháng 6/2019. Đối tượng và phương pháp nghiên cứu: mô tả cắt ngang trên 102 trẻ được xác định ngừng tuần hoàn. Kết quả: Nhóm dưới 1 tuổi thường gặp nhất (43,1%). Ngừng tuần hoàn chủ yếu xảy ra tại khoa cấp cứu và hồi sức cấp cứu (chiếm 49,0% và 43,1%). Tỉ lệ ngừng tuần hoàn nội viện cao hơn so với ngoại viện (68,6% với 31,4%). Trong các bệnh lý gây ngừng tuần hoàn, nguyên nhân do tim mạch chiếm tỉ lệ cao nhất (22,6%), tiếp theo là bệnh nhiễm khuẩn nhất (20,6%) và hô hấp (17,7%). Kết luận: Ngừng tuần hoàn thường xảy ra ở nhóm dưới 1 tuổi và chủ yếu gặp ở khoa cấp cứu và hồi sức cấp cứu. Bệnh lý tim mạch, nhiễm khuẩn và hô hấp là các nguyên nhân thường gặp gây ngừng tuần hoàn.
... Moreover, most of the studies on the epidemiology and outcomes of patients with sepsis who develop IHCA are limited by their use of data extrapolated from cardiac arrest registries, few of which specify sepsis as a subgroup of interest [4][5][6][10][11][12]. In addition, these studies are limited by the variety of sepsis-related diagnoses and changes in the definition of sepsis [10][11][12][13][14][15][16]. The aim of this study was to evaluate the prevalence of IHCA in septic shock patients after admission into the emergency department and to determine 2 of 9 the factors associated with an increased risk of IHCA in patients with septic shock, as defined by the Sepsis-3 criteria. ...
... Patients transferred to another hospital during treatment and those who refused resuscitation treatment were excluded ( Figure 1). and changes in the definition of sepsis [10][11][12][13][14][15][16]. The aim of this study was to evaluate the prevalence of IHCA in septic shock patients after admission into the emergency department and to determine the factors associated with an increased risk of IHCA in patients with septic shock, as defined by the Sepsis-3 criteria. ...
The clinical characteristics and laboratory values of patients with septic shock who experience in-hospital cardiac arrest (IHCA) have not been well studied. This study aimed to evaluate the prevalence of IHCA after admission into the emergency department and to identify the factors that increase the risk of IHCA in septic shock patients. This observational cohort study used a prospective registry of septic shock patients and was conducted at the emergency department of a university-affiliated hospital. The data of 887 adult (age ≥ 18 years) septic shock (defined using the Sepsis-3 criteria) patients who were treated with a protocol-driven resuscitation bundle therapy and were admitted to the intensive care unit between January 2010 and September 2018 were analyzed. The primary endpoint was the occurrence of sepsis-associated cardiac arrest. The patient mean age was 65 years, and 61.8% were men. Sepsis-associated cardiac arrest occurred in 25.3% of patients (n = 224). The 28-day survival rate after cardiac arrest was 6.7%. Multivariate logistic regression identified chronic pulmonary disease (odds ratio (OR) 2.06), hypertension (OR 0.48), unknown infection source (OR 1.82), a hepatobiliary infection source (OR 0.25), C-reactive protein (OR 1.03), and serum lactate level 6 h from shock (OR 1.34). Considering the high mortality rate of sepsis-associated cardiac arrest after cardiopulmonary resuscitation, appropriate monitoring is required in septic shock patients with major risk factors for IHCA.
... Studies reported a significant increase in the rate of post-CPR mortality in developing countries in comparison with the western world 5,6 . One study in Saudi Arabia reported a rate of mortality of 50% 7 , and another of immediate post-CPR mortality of 36% and 70% at discharge 8 . ...
... Our findings contradicted those from other studies which reported a lower rate of mortality among patients in the pediatric intensive care unit (PICU) 5,16 . In our study, the emergency department showed a lower rate than in other departments. ...
Purpose: This study aimed to identify predictors of mortality related to the quality of CPR, victims' pre-CPR characteristics, and the resuscitation characteristics. Design and methods: A descriptive observational design with a non-active approach was used. Data collectors observed the implementation of CPR then recorded the parameters of interest against a pre-structured checklist. A total of 242 CPR events were observed. The study took place in three medical centers in Jordan. Results: The study showed that victims whose CPR took place in the emergency room and those admitted with cardiac and respiratory diseases were more likely to resume spontaneous breathing and circulation. Conclusion: Early identification of patients at high risk for mortality would help to reduce the rate of mortality through quick response and proper resuscitation.
... Es wurden der 2020 PLS COSTR 1541 [143], sowie einige zusätzliche Nicht-RCT für den RR berücksichtigt (Anhang RR 30; [715][716][717][718][719][720][721][722][723][724][725] [14,729,[732][733][734][735][736][737]). Während diese Studien wahrscheinlich durch denZusammenhangzwischenderVerabreichung von Natriumbikarbonat und einer längeren Reanimationsdauer im Sinn eines "confounding" verfälscht werden, lieferte keine Studie Hinweise auf eine Änderung der Empfehlung, dass Bikarbonat nicht routinemäßig bei Kreislaufstillständen im Kindesalter verabreicht werden soll. ...
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
... The results of our study once again proved that the clinical rescue time should be at least more than 30 minutes. [26] The recovery of Sinus rhythm is the prerequisite for the recovery of spontaneous circulation in patients with cardiac arrest. At the same time, the maintenance time of sinus rhythm is also an important prerequisite for keeping vital signs stable after CPR, and it is related to whether other resuscitation techniques have time to be implemented and the final outcome of CPR. ...
No matter in or outside hospital, the success rate of cardiopulmonary resuscitation (CPR) is very low. The sign of successful CPR is the recovery of spontaneous circulation. The premise of the recovery of spontaneous circulation is the recovery and maintenance of sinus rhythm, but there is still no related research.
We aim to study the factors for the recovery and maintenance time of sinus rhythm in patients with CPR.
A single-center retrospective case–control study.
Ethical review was obtained (ethical approval number: 20180031).
The second affiliated hospital of Xi’an Jiaotong University, Xi’an Shaanxi, China.
From January 2011 to December 2016, totally 344 cases met the inclusion and exclusion criteria, sinus rhythm recovered group (SR group) (n = 130 cases), sinus rhythm unrecovered group (SUR group) (n = 214 cases).
The multivariate logistic regression analysis showed that red blood cell counts (OR = 1.30, 95% CI:1.04–1.63, P = .02), rescue time (OR = 0.95, 95% CI:0.94–0.97, P <.001), the usage of norepinephrine (OR = 2.14, 95% CI:1.06–4.35, P = .04) were important factor for the recovery of sinus rhythm in patients with CPR. Multivariate linear regression analysis showed that the dosage of epinephrine, the usage of naloxone and diagnosis were important factors for maintenance time of sinus rhythm after resuscitation, P <.05. The rescue time had high accuracy to predict the recovery of sinus rhythm, the area under the receiver operator characteristic (ROC) curve (AUC) was 0.84 (0.80, 0.88), sensitivity and specificity are respectively 71.54% and 93.46%.
Red blood cell counts, the rescue time and the usage of norepinephrine might be important factors for the recovery of sinus rhythm, and the dosage of epinephrine, the usage of naloxone and the diagnosis might be important factors for the maintenance time of sinus rhythm in patients with CPR.
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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 4,877 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).
Aim
To report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database.
Methods
Analysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children’s hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge.
Results
For this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children’s hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively.
Conclusions
These first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.
Objective:
To determine the initial defibrillation energy dose that is associated with sustained return of spontaneous circulation (ROSC) during paediatric cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia.
Methods:
A systematic review was performed using four databases (PROSPERO: CRD42016036734). Human studies and animal model studies of pediatric cardiac arrest involving assessment of external defibrillation energy dosing were considered. The primary outcome was sustained ROSC. Survival and defibrillation-induced complications were also evaluated.
Results:
The search strategy identified 14,471 citations of which 232 manuscripts were reviewed. Ten human and 10 animal model studies met the inclusion criteria. Human studies were prospective (n = 6) or retrospective (n = 4) cohort studies and included between 11 and 266 patients (median = 46 patients). Sustained ROSC rates ranged from 0 to 61% (n = 7). No studies reported a statistically significant association between the initial defibrillation energy dose and the rate of sustained ROSC (n = 7) or survival (n = 6). Meta-analysis was not considered appropriate due to clinical heterogeneity. Risk of bias was moderate. All animal studies were randomized controlled trials with 8 and 52 (median = 27) piglets. ROSC was frequently achieved (≥85%) with energy dose ranging from 2 to 7 J/kg (n = 7). The defibrillation threshold varied according to the body weight and appears to be higher in infant.
Conclusion:
Defibrillation energy doses and thresholds varied according to the body weight and trended higher for infants. No definitive association between initial defibrillation doses and the sustained ROSC or survival could be demonstrated. Clinicians should follow local consensus-based guidelines.
Background: There are scarce data on outcomes of in-hospital paediatric cardiac arrest (CA) in resource-poor settings and none for World Bank-defined low-income countries.
Aim: To report the outcomes of in-hospital paediatric CA from a university-affiliated referral hospital in Malawi.
Methods: Data were collected prospectively on patients aged 30 days to 13 years who experienced CA and underwent cardiopulmonary resuscitation (CPR) at Kamuzu Central Hospital in Lilongwe, Malawi from January through June 2017. Utstein-style reporting guidelines for CAs were used to define outcomes; the primary outcome was survival to hospital discharge. A data collection form was used to record patient, arrest and resuscitation characteristics.
Results: A total of 135 patients fulfilled the criteria for inclusion in the study. Resuscitation outcomes are presented in Figure 1 using a modified Utstein template. In-hospital CA was associated with 100% mortality. Return of spontaneous circulation (ROSC) was obtained in 6% of patients and sustained ROSC in 4%; 24-h survival was zero. The most common admission diagnosis was malaria (51%). Most arrests occurred on the paediatric ward (90%) rather than critical care units. Most resuscitations were led by trainees and mid-level providers (58%) rather than paediatricians (23%).
Conclusion: Survival following in-hospital paediatric CA was zero, suggesting that CPR may have no benefit in this tertiary hospital. Future efforts to improve outcomes should focus on advocating better pre-arrest care and research interventions aimed to identify and treat children at risk of CA within the resource constraints of this setting.
Sepsis-associated cardiac arrest is a relatively common occurrence with especially poor outcomes. Of the greater than 200,000 in-hospital cardiac arrests that occur in the United States annually, between 30,000 and 60,000 occur in patients with underlying sepsis. These patients are less likely to survive than cardiac arrest victims without sepsis. In this review, we discuss the epidemiology of sepsis-associated in-hospital cardiac arrest in adults and children, the relevant physiology responsible for its pathogenesis and poor outcomes, and potential therapeutic interventions based on this pathophysiology. We postulate that persistence of sepsis pathophysiology during and after cardiac arrest is responsible for these poor outcomes. This includes derangements of vascular tone and intravascular volume status; myocardial dysfunction; hypoxemia, acidemia, and other metabolic derangements; and pulmonary hypertension. Potential interventions that specifically target this pathophysiology before, during, and after cardiac arrest may augment standard cardiopulmonary resuscitation and post-resuscitation care for patients with sepsis and septic shock.
Purpose:
To analyze prognostic factors associated with in-hospital cardiac arrest (CA) in children.
Methods:
A prospective, multicenter, multinational, observational study was performed on pediatric in-hospital CA in 12 countries and included 502 children between 1 month and 18 years. The primary endpoint was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality.
Results:
Return of spontaneous circulation was achieved in 69.5 % of patients; 39.2 % survived to hospital discharge and 88.9 % of survivors had good neurological outcome. The pre-arrest factors related to mortality were lower Human Development Index [odds ratio (OR) 2.32, 95 % confidence interval (CI) 1.28-4.21], oncohematologic disease (OR 3.33, 95 % CI 1.60-6.98), and treatment with inotropic drugs at the time of CA (OR 2.35, 95 % CI 1.55-3.56). CA and resuscitation factors related to mortality were CA due to neurological disease (OR 5.19, 95 % CI 1.49-18.73) and duration of cardiopulmonary resuscitation greater than 10 min (OR 4.00, 95 % CI 1.49-18.73). Factors related to survival were CA occurring in the pediatric intensive care unit (PICU) (OR 0.38, 95 % CI 0.16-0.86) and shockable rhythm (OR 0.26, 95 % CI 0.09-0.73).
Conclusions:
In-hospital CA in children has a low survival but most of the survivors have a good neurological outcome. Some prognostic risk factors cannot be modified, making it important to focus efforts on improving hospital organization to care for children at risk of CA in the PICU and, in particular, in other hospital areas.
According to World Health Organization estimates, sepsis accounts for 60%-80% of lost lives per year in childhood. Measures appropriate for resource-scarce and resource-abundant settings alike can reduce sepsis deaths. In this regard, the World Federation of Pediatric Intensive Care and Critical Care Societies Board of Directors announces the Global Pediatric Sepsis Initiative, a quality improvement program designed to improve quality of care for children with sepsis.
To announce the global sepsis initiative; to justify some of the bundles that are included; and to show some preliminary data and encourage participation.
The Global Pediatric Sepsis Initiative is developed as a Web-based education, demonstration, and pyramid bundles/checklist tool (http://www.pediatricsepsis.org or http://www.wfpiccs.org). Four health resource categories are included. Category A involves a nonindustrialized setting with mortality rate <5 yrs and >30 of 1,000 children. Category B involves a nonindustrialized setting with mortality rate <5 yrs and <30 of 1,000 children. Category C involves a developing industrialized nation. In category D, developed industrialized nation are determined and separate accompanying administrative and clinical parameters bundles or checklist quality improvement recommendations are provided, requiring greater resources and tasks as resource allocation increased from groups A to D, respectively.
In the vanguard phase, data for 361 children (category A, n = 34; category B, n = 12; category C, n = 84; category D, n = 231) were successfully entered, and quality-assurance reports were sent to the 23 participating international centers. Analysis of bundles for categories C and D showed that reduction in mortality was associated with compliance with the resuscitation (odds ratio, 0.369; 95% confidence interval, 0.188-0.724; p < .0004) and intensive care unit management (odds ratio, 0.277; 95% confidence interval, 0.096-0.80) bundles.
The World Federation of Pediatric Intensive Care and Critical Care Societies Global Pediatric Sepsis Initiative is online. Success in reducing pediatric mortality and morbidity, evaluated yearly as a measure of global child health care quality improvement, requires ongoing active recruitment of international participant centers. Please join us at http://www.pediatricsepsis.org or http://www.wfpiccs.org.
To review the characteristics and outcome of cardiopulmonary resuscitation in children at a rural hospital in Kenya.
All children aged 0-14 years who experienced > or =1 episode of respiratory or cardiopulmonary arrest during April 2002--2004 were prospectively identified. Demographic variables, cause of hospitalisation, type and duration of arrest, resuscitation measures taken and outcomes were determined.
114 children experienced at least one episode of respiratory arrest (RA) or cardiopulmonary arrest (CPA). Cardiopulmonary resuscitation (CPR) was performed on all children. "Do not resuscitate order" (DNR) was given in 15 patients after initial resuscitation. Eighty two patients (72%) had RA and 32 (28%) had CPA. 25/82 (30%) patients with RA survived initial CPR compared to 5/32 (16%) with CPA. Survival at discharge was 22% (18/82) in children who had RA while no one with CPA survived at discharge. The leading underlying diseases were severe malaria, septicaemia and severe malnutrition. Prolonged resuscitation beyond 15 min and receiving adrenaline [epinephrine] (at least one dose of 10 microg/kg IV) were predictive of poor final outcome.
Cardiopulmonary arrest after admission has a very poor prognosis in our hospital. Infectious diseases are the main underlying causes of arrest. If a child fails to respond to the basic tenements of PALS within 15 min then it is unlikely that further efforts to sustain life will be fruitful in hospitals where ventilation facilities are not present.
Data regarding pediatric in-hospital cardiopulmonary resuscitation (CPR) have been limited because of retrospective study designs, small sample sizes, and inconsistent definitions of cardiac arrest and CPR. The purpose of this study was to prospectively describe and evaluate pediatric in-hospital CPR with the international consensus-derived epidemiologic definitions from the Utstein guidelines.
All 129 in-hospital CPRs during 12 months at a 122-bed university children's hospital in Sao Paulo, Brazil, were described and evaluated using Utstein reporting guidelines. These guidelines include standardized descriptions of hospital variables, patient variables, arrest/event variables, and outcome variables. CPR was defined as chest compressions and assisted ventilation provided because of cardiac arrest or because of severe bradycardia with poor perfusion. Outcome variables included sustained return of spontaneous circulation, 24-hour survival, 30-day survival, 1-year survival, and neurologic status of survivors by the Pediatric Cerebral Performance Category Scale.
Of the 6024 children admitted to the hospital, 176 (3%) had an episode that met the criteria for provision of CPR and 129 (2%) received CPR, 86 for clinical cardiac arrest and 43 for bradycardia with poor perfusion. Most of the children (71%) had preexisting chronic diseases. The most common precipitating causes were respiratory failure (61%) and shock (29%). The initial cardiac rhythm was asystole in 71 children (55%), pulseless electrical activity in 12 (9%), ventricular fibrillation in 1, and bradycardia with pulses and poor perfusion in 43 (33%). Eighty-three children (64%) attained sustained return of spontaneous circulation (>20 minutes), 43 (33%) were alive at 24 hours, 24 (19%) were alive at 30 days, and 19 (15%) were alive at 1 year. Although many factors correlated with 24-hour survival, multivariate logistic regression analysis revealed independent association of 24-hour survival with respiratory failure as the precipitating cause (odds ratio [OR]: 4.92; 95% confidence interval [CI]: 1.73-14.0), bradycardia with pulses as the initial event (OR: 2.68; 95% CI: 1.01-7.1), and shorter duration of CPR (OR: 0.92; 95% CI: 0.89-0.96 for each elapsed minute). Similarly, 30-day survival was independently associated with respiratory failure as the precipitating cause and shorter duration of CPR. Thirty-day survival decreased by 5% with each elapsed minute of CPR. Nineteen (91%) of the 21 survivors to hospital discharge and 16 (83%) of the 19 1-year survivors had no demonstrable long-term change in neurologic function from their pre-CPR status.
During this study, CPR was uncommon but not rare. Respiratory failure was the most common precipitating cause, followed by shock. Preexisting chronic diseases were prevalent among these children. Asystole was the most common initial cardiac rhythm, and bradycardia with pulses and poor perfusion was the second most common. Ventricular fibrillation was rare, but children with acute cardiac diseases, such as cardiac surgery and acute cardiomyopathies, were not admitted to this children's hospital. CPR was effective: nearly two thirds of these children were initially successfully resuscitated, and one third were alive at 24 hours compared with imminent death without CPR and advanced life support. Nevertheless, survival progressively decreased over time, generally as a result of the underlying disease process. One-year survival was 15%. Importantly, most of these survivors had no demonstrable change in gross neurologic function from their pre-CPR status.
Evaluate the efficacy of advanced life support interventions using the pediatric Utstein guidelines.
Charts from all patients for whom a cardiorespiratory arrest code was called during a six-year period in a university affiliated centre were reviewed. Data were recorded according to the pediatric Utstein guidelines and a P < 0.05 was considered significant.
Of the 234 calls, 203 were retained for analysis. The overall survival rate at one year was 26.0% of which 10% had deterioration of their neurologic status compared to the pre-cardiorespiratory arrest evaluation. Time to achieve sustained return of spontaneous circulation (ROSC; P < 0.0001) and sustained measurable blood pressure (P = 0.002), to perform endotracheal intubation (P = 0.04) and the dose of sodium bicarbonate (P < 0.0001) were indicators of long-term survival. Two patients were alive at one year with unchanged neurologic status despite a time to achieve sustained ROSC longer than 30 min (38 and 44 min). The mean first epinephrine dose of patients for whom ROSC was achieved but unsustained was higher than those for whom ROSC was achieved and sustained (0.038 +/- 0.069 mg*kg(-1) vs 0.011 +/- 0.006 mg*kg(-1); P = 0.004). Survival rate and mean first epinephrine dose of patients who received their first epinephrine dose endotracheally (13.3%; 0.011 +/- 0.004 mg*kg(-1)) were comparable to those of patients who received their first epinephrine dose intravenously (7%; 0.015 +/- 0.027 mg*kg(-1)).
For intravenously administered epinephrine, a dose of 0.01 mg*kg(-1) seems appropriate as the first dose. The endotracheal route is a valuable alternative for epinephrine administration and, for infants, the dose does not need to be increased. A minimal resuscitation duration time of 30 min can be misleading if ROSC is used as the indicator.
Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA.
To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes.
A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36,902 adults (> or =18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded.
Survival to hospital discharge.
The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/880] vs 18% [6485/36,902]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36,902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11,963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24,987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32).
In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
Age is an important determinant of outcome from adult cardiac arrests but has not been identified previously as an important factor in pediatric cardiac arrests except among premature infants. Chest compressions can result in more effective blood flow during cardiac arrest in an infant than an older child or adult because of increased chest wall compliance. We, therefore, hypothesized that survival from cardiac arrest would be better among infants than older children.
We evaluated 464 pediatric ICU arrests from the National Registry of Cardiopulmonary Resuscitation from 2000 to 2002. NICU cardiac arrests were excluded. Data from each arrest include >200 variables describing facility, patient, prearrest, arrest intervention, outcome, and quality improvement data. Age was categorized as newborn (<1 month; N = 62), infant (1 month to <1 year; N = 105), younger child (1 year to <8 years; N = 90), and older child (8 years to <21 years; N = 207). Multivariable logistic regression was performed to examine the association between age and survival.
Overall survival was 22%, with 27% of newborns, 36% of infants, 19% of younger children and 16% of older children surviving to hospital discharge. Newborns and infants demonstrated double and triple the odds of surviving to hospital discharge from a cardiac arrest in an intensive care setting when compared with older children. When potential confounders were controlled, newborns increased their advantage to almost fivefold, while infants maintained their survival advantage to older children.
Survival from pediatric ICU cardiac arrest is age dependent. Newborns and infants have better survival rates even after adjusting for potential confounding variables.
Introduction of a rapid response team (RRT) has been shown to decrease mortality and cardiopulmonary arrests outside of the intensive care unit (ICU) in adult inpatients. No published studies to date show significant reductions in mortality or cardiopulmonary arrests in pediatric inpatients.
To determine the effect on hospital-wide mortality rates and code rates outside of the ICU setting after RRT implementation at an academic children's hospital.
A cohort study design with historical controls at a 264-bed, free-standing, quaternary care academic children's hospital. Pediatric inpatients who spent at least 1 day on a medical or surgical ward between January 1, 2001, and March 31, 2007, were included. A total of 22,037 patient admissions and 102,537 patient-days were evaluated preintervention (before September 1, 2005), and 7257 patient admissions and 34,420 patient-days were evaluated postintervention (on or after September 1, 2005).
The RRT included a pediatric ICU-trained fellow or attending physician, ICU nurse, ICU respiratory therapist, and nursing supervisor. This team was activated using standard criteria and was available at all times to assess, treat, and triage decompensating pediatric inpatients.
Hospital-wide mortality rates and code (respiratory and cardiopulmonary arrests) rates outside of the ICU setting. All outcomes were adjusted for case mix index values.
After RRT implementation, the mean monthly mortality rate decreased by 18% (1.01 to 0.83 deaths per 100 discharges; 95% confidence interval [CI], 5%-30%; P = .007), the mean monthly code rate per 1000 admissions decreased by 71.7% (2.45 to 0.69 codes per 1000 admissions), and the mean monthly code rate per 1000 patient-days decreased by 71.2% (0.52 to 0.15 codes per 1000 patient-days). The estimated code rate per 1000 admissions for the postintervention group was 0.29 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.65; P = .008), and the estimated code rate per 1000 patient-days for the postintervention group was 0.28 times that for the preintervention group (95% likelihood ratio CI, 0.10-0.64; P = .007).
Implementation of an RRT was associated with a statistically significant reduction in hospital-wide mortality rate and code rate outside of the pediatric ICU setting.
Outcome after cardiac arrest and cardiopulmonary resuscitation is dependent on critical interventions, particularly early defibrillation, effective chest compressions, and advanced life support. Utstein-style definitions and reporting templates have been used extensively in published studies of cardiac arrest, which has led to greater understanding of the elements of resuscitation practice and progress toward international consensus on science and resuscitation guidelines. Despite the development of Utstein templates to standardize research reports of cardiac arrest, international registries have yet to be developed. In April 2002, a task force of the International Liaison Committee on Resuscitation (ILCOR) met in Melbourne, Australia, to review worldwide experience with the Utstein definitions and reporting templates. The task force revised the core reporting template and definitions by consensus. Care was taken to build on previous definitions, changing data elements and operational definitions only on the basis of published data and experience derived from those registries that have used Utstein-style reporting. Attention was focused on decreasing the complexity of the existing templates and addressing logistical difficulties in collecting specific core and supplementary (ie, essential and desirable) data elements recommended by previous Utstein consensus conferences. Inconsistencies in terminology between in-hospital and out-of-hospital Utstein templates were also addressed. The task force produced a reporting tool for essential data that can be used for both quality improvement (registries) and research reports and that should be applicable to both adults and children. The revised and simplified template includes practical and succinct operational definitions. It is anticipated that the revised template will enable better and more accurate completion of all reports of cardiac arrest and resuscitation attempts. Problems with data definition, collection, linkage, confidentiality, management, and registry implementation are acknowledged and potential solutions offered. Uniform collection and tracking of registry data should enable better continuous quality improvement within every hospital, emergency medical services system, and community.
[Utstein Style Writing Group: Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: The in-hospital “Utstein style.” Ann Emerg Med May 1997;29:650-679.]
To aggregate data across institutions to identify, characterize, and differentiate potential survivors from nonsurvivors based on etiology of event.
To evaluate the association of the cardiopulmonary resuscitation (CPR) duration and probability of survival (Ps), stratified by etiology of arrest.
In-hospital cardiac arrests occur in 2-6% of pediatric patients with poor survival rates resulting in significant expenditures of time and resources.
Retrospective data from six pediatric hospitals on patients suffering from pulseless cardiac arrests receiving CPR for over one minute were analyzed. Data included demographics, reason for code, precardiac arrest diagnosis, devices and treatment, management strategies during cardiac arrest, compression duration, outcome at hospital discharge, and neurologic outcome of survivors at hospital discharge. Results of logistic regression analysis generated predicated probabilities of survival for duration of compression. Patients were stratified by cardiac-induced cardiac arrests (CICA) and respiratory-induced cardiac arrest (RICA).
A total of 257 patients were included, and 27% of CICA and 35% of RICA patients survived to hospital discharge. Ps was initially lower for the CICA patients (Ps at 1 min = 29%) and remained constant (Ps at 60 min = 25%). RICA patients'Ps was higher initially (Ps at 1 min = 62%) but demonstrated a dramatic drop within the first 60 min of CPR (Ps at 60 min = 0.2%).
Probability of survival curves based on duration of CPR was statistically significantly different for CICA patients compared to RICA patients.
The 'chain of survival' has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring 'chain of survival'. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings--a 'chain of prevention'--to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent 'staff education', 'monitoring', 'recognition', the 'call for help' and the 'response'. It is believed that a 'chain of prevention' has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems.
It is possible that the exportation of North American and European models has hindered the creation of a structured cardiopulmonary resuscitation (CPR) training programme in developing countries. The objective of this paper is to describe the design and present the results of a European paediatric and neonatal CPR training programme adapted to Honduras.
A paediatric CPR training project was set up in Honduras with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The programme was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching.
During the first phase, 24 Honduran doctors from paediatric intensive care, paediatric emergency and anaesthesiology departments attended the paediatric CPR course and 16 of them the course for preparation as instructors. The Honduran Paediatric and Neonatal CPR Group was formed. In the second phase, workshops were given by Honduran instructors and four of them attended a CPR course in Spain as trainee instructors. In the third phase, a CPR course was given in Honduras by the Honduran instructors, supervised by the Spanish team. In the final phase of independent teaching, eight courses were given, providing 177 students with training in CPR.
The training of independent paediatric CPR groups with the collaboration and scientific assessment of an expert group could be a suitable model on which to base paediatric CPR training in Latin American developing countries.
Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time.
An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades.
Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.
: To describe a large multicenter cohort of pediatric cardiac arrest (CA) with return of circulation (ROC) from either the in-hospital (IH) or the out-of-hospital (OH) setting and to determine whether significant differences related to pre-event, arrest event, early postarrest event characteristics, and outcomes exist that would be critical in planning a clinical trial of therapeutic hypothermia (TH).
: Retrospective cohort study.
: Fifteen Pediatric Emergency Care Applied Research Network sites.
: Patients aged 24 hours to 18 years with either IH or OH CA who had a history of at least 1 minute of chest compressions and ROC for at least 20 minutes were eligible.
: None.
: A total of 491 patients met study entry criteria with 353 IH cases and 138 OH cases. Major differences between the IH and OH cohorts were observed for patient prearrest characteristics, arrest event initial rhythm described, and arrest medication use. Several postarrest interventions were used differently, however, the use of TH was similar (<5%) in both cohorts. During the 0-12-hour interval following ROC, OH cases had lower minimum temperature and pH, and higher maximum serum glucose recorded. Mortality was greater in the OH cohort (62% vs. 51%, p = 0.04) with the cause attributed to a neurologic indication much more frequent in the OH than in the IH cohort (69% vs. 20%; p < 0.01).
: For pediatric CA with ROC, several major differences exist between IH and OH cohorts. The finding that the etiology of death was attributed to neurologic indications much more frequently in OH arrests has important implications for future research. Investigators planning to evaluate the efficacy of new interventions, such as TH, should be aware that the IH and OH populations differ greatly and require independent clinical trials.
1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest.
Retrospective cohort study.
Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network.
Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for >1 min, and had a return of circulation for >20 mins.
None.
A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness.
Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.
To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death.
Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET).
Tertiary care pediatric hospital.
A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET.
Introduction of a MET.
Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57-0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13- 0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 -1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20-0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03-0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11- 4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1).
Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.
While the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.
Data were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).
We identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p<0.05).
Outcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.
This scientific statement is the product of the Utstein ’95 Symposium held June 23-24, 1995, at Utstein Abbey, Island of Mosteroy, Rogaland County, Norway. Draft versions were circulated for comment to participants of the Utstein ’95 Symposium; the European Resuscitation Council Executive Committee; the Emergency Cardiac Care Committee of the American Heart Association; the Executive Committees of the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa; and several outside reviewers. The development of this statement was authorized by the Science Advisory and Coordinating Committee of the AHA and the Executive Committee of the European Resuscitation Council.
We do not know the true effectiveness of in-hospital resuscitation. Observed results of the many published studies vary greatly. Studies originate from different settings and have different patient populations. Reports suffer from nonuniform nomenclature and variable inclusion definitions. Patients differ in the extent of comorbid conditions and interventions in place at the time of cardiac arrest. These differences prevent valid interhospital and intrahospital comparisons and make determining the effectiveness of current resuscitation techniques impossible.
To develop these guidelines the task force used a consensus development process that originated with the “Utstein style” for reporting outcome data from out-of-hospital resuscitation events. Task force members performed an integrated review of published studies. An initial draft was prepared, discussed, and revised at a 2-day conference. Further drafts were revised and circulated among task force members and discussed face-to-face at three subsequent meetings.
The task force defined a set of data elements that are essential or desirable for documenting in-hospital cardiac arrest. Data categories are hospital variables, patient variables, arrest variables, and outcome variables. The “In-Hospital Utstein-Style Template” was developed to summarize these data and recommendations for reporting a specific set of survival rates and outcomes. The task force …
To determine the effectiveness of cardiopulmonary resuscitation (CPR) in the pediatric intensive care unit (ICU).
A nonconcurrent cohort study of consecutive admissions.
Thirty-two pediatric ICUs.
Consecutive admissions to 32 pediatric ICUs.
None.
Pediatric ICU patients were followed for the occurrence of a cardiopulmonary arrest (external cardiac massage for at least 2 mins). Patients who were in a state of continuous cardiopulmonary arrest on admission, or who never achieved stable vital signs, were excluded from the study. A total of 205 patients, from a sample of 11,165 (1.8%) pediatric admissions, experienced a cardiopulmonary arrest. Overall, 28 (13.7%) patients survived to hospital discharge. Neither mean ages nor age distribution affected survival. Only two diagnostic categories, traumatic illness, and other etiologies, were associated with survival. None of the patients fitting this category survived (p = .0028). The durations of CPR for survivors and nonsurvivors were 22.5 +/- 10.1 and 24.8 +/- 1.9 mins, respectively (p = .015). For CPR durations of <15 mins, 15 to 30 mins, and >30 mins, the survival rates were 18.6%, 12.2%, and 5.6%, respectively (linear trend p = .022). Thirty-five (17.1%) patients had a cardiopulmonary arrest before pediatric ICU admission and another arrest in the pediatric ICU. Only two (5.7%) of these 35 patients survived to discharge. Pediatric ICU survival decreased as the number of pediatric ICU arrests increased. Patients with one arrest (n = 155), two arrests (n = 29), and more than three arrests (n = 21) experienced survival rates of 14%, 14%, and 9.5%, respectively. Severity of illness, as measured by the Pediatric Risk of Mortality III score, was a significant predictor of survival (p < .001).
Pediatric ICU cardiac arrest is an uncommon event. When it does occur, prehospital CPR, duration of resuscitation, traumatic etiology, and severity of illness are important factors associated with survival.
To report paediatric in-hospital cardiac arrest data according to Utstein style and to determine the effectiveness of cardiopulmonary resuscitation (CPR) in hospitalized children. Design: Retrospective 5-year case series.
Urban, tertiary-care children's hospital.
All patients who sustained cardiopulmonary arrest.
Altogether 227 patients experienced a cardiopulmonary arrest during the study period, 109 (48.0%) were declared dead without attempted resuscitation, and CPR was initiated in 118 (52.0%). The incidence of cardiac arrest was 0. 7% of all hospital admissions and 5.5% of PICU admissions; the incidence of CPR attempts was 0.4 and 2.5%, respectively. Most of the CPR attempts (64.4%) took place in the PICU and the most frequent aetiology was cardiovascular (71.2%). The 1-year survival rate was 17.8%. Short duration of external CPR was the best prognostic factor associated with survival. With few exceptions, the Paediatric Utstein Style was found to be applicable for reporting retrospective data from in-hospital cardiac arrests in children.
In-hospital cardiopulmonary resuscitation was shown to be an uncommon event in children; the survival rate was similar to earlier studies.
Given the current focus on outcomes, there is a crucial need for easily utilized measures that can effectively quantify morbidity or disability after a child's critical illness or injury. The purpose of this study is to significantly extend the research on two such promising measures: the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC).
Cross-sectional analysis of a sample of pediatric intensive care unit (PICU) discharges and a prospective follow-up of this cohort of children.
Arkansas Children's Hospital.
Two hundred children (ranging in age from birth to 21 yrs) discharged from a PICU.
None.
Data were collected at PICU discharge, hospital discharge, and 1- and 6-month follow-up assessments after hospital discharge. Measures utilized included the POPC (at PICU discharge), PCPC (at PICU discharge), Stanford-Binet Intelligence Scale, fourth edition (at hospital discharge), Bayley Scales of Infant Development, second edition (at hospital discharge), and the Vineland Adaptive Behavior Scales (at 1 and 6 months after discharge). Stanford-Binet Intelligence Quotients and Bayley Mental Developmental Index scores were significantly different across PCPC categories (p < .0001). Bayley Psychomotor Developmental Index scores and Vineland Adaptive Behavior Scales scores varied significantly across POPC categories (p < .0001). The test for linear trend was also significant for each of the comparisons.
The results of this study offer additional support for the use of the PCPC and POPC. These brief and easily completed measures can provide useful information regarding probable outcomes for pediatric intensive care patients when more extensive psychometric testing is not feasible or desirable.
To analyse the present day characteristics and outcome of cardio-respiratory arrest in children in Spain.
An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital cardio-respiratory arrest in children. Patients and methods: Two hundred and eighty-three children between 7 days and 17 years of age with cardio-respiratory arrest. Data were recorded according to the Utstein style. The outcome variables were the sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). Three hundred and eleven cardio-respiratory arrest episodes, composed of 70 respiratory arrests and 241 cardiac arrests in 283 children were studied. Accidents were the most frequent cause of out-of-hospital arrest (40%), and cardiac disease was the leading cause (31%) of in-hospital arrest. Initial survival was 60.2% and 1 year survival was 33.2%. The final survival was higher in patients with respiratory arrest (70%) than in patients with cardiac arrest (21.1%) (P <0.0001). Although many individual factors correlated with mortality, multivariate logistic regression revealed that the best indicator of mortality was a duration of cardiopulmonary resuscitation of over 20 min (odds ratio: 10.35; 95% CI 4.59-23.32).
In Spain, the present mortality from cardio-respiratory arrest in children remains high. Survival after respiratory arrest is significantly higher than after cardiac arrest. The duration of cardiopulmonary resuscitation attempt is the best indicator of mortality of cardio-respiratory arrest in children.
To describe the incidence, survival, and neurologic outcome of in-intensive-care-unit (ICU) cardiac arrest and to identify factors predictive of survival to hospital discharge.
We performed a retrospective cohort study. Eligible patients were <18 yrs of age and experienced a cardiac arrest during their admission to a multidisciplinary pediatric intensive care unit in the 5.5-yr period ending June 2002. Cardiac arrest was defined as the administration of chest compressions or defibrillation for a nonperfusing cardiac rhythm. Mortality and the Paediatric Cerebral Performance Score were measured and presented according to the Utstein style. Factors predictive of survival to hospital discharge were identified by univariate analysis and independent predictors were identified by multivariate analysis.
Ninety-one children had cardiac arrest, yielding an incidence of 0.94 cardiac arrests per 100 admissions. Resuscitation was successful in 75 (82%) children, 61 (67%) survived 24 hrs, 25 (27%) children survived to ICU discharge and 23 (25%) to hospital discharge. At hospital discharge, the median Pediatric Cerebral Performance Category score was 2 (range, 1-3) and the median Pediatric Overall Performance Category score was 3 (range, 1-4). No child was assessed as normal on both scores. The independent positive predictors of hospital mortality were the presence of renal failure before cardiac arrest (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.8-31), being on epinephrine infusion at time of cardiac arrest (OR, 9.5; 95% CI, 1.5-62), and the administration of one or more calcium boluses during resuscitation (OR, 5.4; 95% CI, 1.1-25). The use of extracorporeal membrane oxygenation (ECMO) within 24 hrs after cardiac arrest was associated with reduced hospital mortality (OR, 0.18; 95% CI, 0.04-0.76).
In-ICU cardiac arrest is associated with high in-hospital mortality and subsequent morbidity in survivors. Prearrest renal dysfunction and epinephrine infusion were associated with increased in-hospital mortality. The use of post-arrest ECMO within 24 hrs was associated with reduced mortality. Rigorous prospective evaluation of the role of ECMO following cardiac arrest is needed.
Cardiac arrest is uncommon among pediatric patients. Prehospital data demonstrate differences in care processes between children and adults receiving cardiopulmonary resuscitation and advanced life support. We sought to evaluate whether children receiving in-hospital cardiopulmonary resuscitation would attain superior 24-hour survival in hospitals with a higher level of pediatric physician staffing, greater intensity of pediatric care services, and higher pediatric patient volume.
A retrospective cohort of 778 hospital inpatients aged < 18 years receiving cardiopulmonary resuscitation was identified from the National Registry of Cardiopulmonary Resuscitation from January 2000 to December 2002. Data on hospital pediatric facilities were obtained via telephone survey. Univariate analyses comparing 24-hour survivors and nonsurvivors were conducted using Wilcoxon rank-sum testing for continuous variables and chi2 analysis for dichotomous variables. Multivariate regression analysis was done to examine hospital characteristics as independent predictors of 24-hour survival.
Complete data were available for 677 patients. Univariate analyses showed an association between several pediatric-specific facility characteristics and 24-hour survival. After accounting for indicators of pre-event clinical condition and monitoring, multivariate analysis showed improved 24-hour survival in hospitals staffed by pediatric residents and surgeons and pediatric residents, surgeons, and fellows than for hospitals with no pediatric physician staffing or pediatric surgeons alone. Measures of available facilities and patient volume were not associated with improved outcome.
Improved 24-hour survival for children receiving in-hospital cardiopulmonary resuscitation is associated with the presence of pediatric residents and fellows.
To evaluate the outcome and quality of in-hospital cardiopulmonary resuscitation (CPR), and factors affecting the outcome.
A 2300-bed university hospital in Thailand.
A 1-year prospective audit according to the Utstein style.
A total of 639 cardiac arrests (370 male, 269 female, age 1 day-96 years, mean+/-S.D.=53.3+/-24.12 years) were included. Four hundred and thirty-three cardiac arrests (67.8%) occurred in non-monitored areas and 200 (31.3%) occurred in monitored areas. Five hundred and thirty-six cardiac arrests (84%) were witnessed. The majority of cardiac arrests occurred in medical patients (68.4%) and surgical patients (21.4%). The most common underlying causes of arrest were respiratory failure (24.7%) and septic shock (23.3%). Initial ECG rhythms were ventricular fibrillation 79 (12.4%), asystole 272 (42.6%) with pulseless electrical activity 225 (35.2%). Most patients received basic life support within 1 min (86.7%) and advanced life support (ALS) within 4 min (92.6%) but only 25% of patients received defibrillation within 3 min. Following resuscitation, 394 (61.7%) achieved restoration of spontaneous circulation and 44 patients (6.9%) survived to discharge. Only 162 post-arrest patients were treated in the critical care area. The initial survival rate was not associated with sex, age and time to ALS, but was significantly related to the monitored area.
In our setting, survival to discharge is 6.9%. Initial survival rate was strongly associated with being in a monitored area. Defibrillators and the critical care areas were insufficient.
To analyse the immediate effectiveness of resuscitation and long-term outcome of children who suffered a cardiorespiratory arrest when admitted to paediatric intensive care units (PICU).
Secondary analysis of data from an 18-month prospective, multicentre study analysing cardiorespiratory arrest in children in 16 paediatric intensive care units in Spain.
We studied 116 children between 7 days and 17 years of age. Data were recorded according to the Utstein style. Analysed outcome variables were sustained return of spontaneous circulation (ROSC), survival to hospital discharge and survival at 1 year. Neurological and general performance outcome was assessed by means of the Paediatric Cerebral Performance Category (PCPC) and the Paediatric Overall Performance Category (POPC) scales.
None.
In 80 patients (69%) ROSC was achieved and it was sustained > 20 min in 69 (59.5%). At one-year follow-up, 40 children (34.5%) were alive. Survival was not associated with sex, age or weight of patients. Mortality from cardiac arrest was higher than respiratory arrest (69.8% versus 40%, p = 0.01). Patients with sepsis had a higher mortality than other diagnostic groups. Mechanically ventilated children and those treated with vasoactive drugs had a higher mortality. Initial mortality was slightly higher in patients with slow ECG rhythms (35.7%) compared to those with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (27.2%). Duration of resuscitation effort was correlated with mortality (p < 0.0001). Patients who required one or more doses of adrenaline had also a higher mortality (77.8% versus 20.7%, p < 0.0001) and survivors needed less doses of adrenaline (0.85 +/- 1.14 versus 4.4+/-2.9, p < 0.0001). At hospital discharge 86.8 and 84.6% of patients had scores 1 or 2 (normal or near-normal) in the PCPC and POPC scales. At 1-year follow-up these figures were 90.8 and 86.3%, respectively.
One-third of children who suffer a cardiac or respiratory arrest when admitted to PICU survive, and most of them had a good long-term neurological and functional outcome. The duration of cardiopulmonary resuscitation attempts is the best indicator of mortality.
Few prospective studies of the incidence and outcome of paediatric in-hospital cardiopulmonary arrest have been reported to enable quality assurance comparisons within and between institutions.
All cardiac and respiratory arrests and their management over a 41-month period in children not subject to palliative treatment or to a 'do not resuscitate' order were recorded and analysed using the Utstein template.
Cardiac arrest occurred in a total of 111 of 104,780 admissions (1.06/1000) while respiratory arrest alone occurred in 36 (0.34/1000). Return of spontaneous circulation (ROSC) was achieved in 81 patients (73%) in cardiac arrest but only 40 (36%) were discharged from hospital and 38 (34%) survived for 1 year. The 1-year survival from respiratory arrest alone was 97%. Cardiac arrest was four times more common (89 versus 22) and approximately 90 times the incidence in the intensive care unit compared with wards but 1-year survival was similar (34% versus 36%). The initial heart rhythms were hypotensive-bradycardia in 73 (66%) with 38% survival; asystole in 17 (15%) with 12% survival; ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 10 (9%) with 40% survival; pulseless electrical activity (PEA) in 10 (9%) with 30% survival and SVT in 1 with survival. Secondary ventricular fibrillation occurred in 15 children given adrenaline (epinephrine) for treatment of asystole, hypotensive-bradycardia or PEA of whom 11 had received adrenaline in an initial dose of > 15 mcg/kg and 4 had < 15 mcg/kg (P = 0.0013). Eleven of 15 patients (73%) in secondary VF never achieved ROSC.
In-patient paediatric cardiac arrest has a mediocre outcome with a better outlook if the initial rhythm is hypotensive-bradycardia, VF or pulsatile VT. Doses of adrenaline greater than 15 mcg/kg given for non-shockable rhythms may cause secondary VF which has a worse outcome than primary VF.
Pediatric Emergency Care Applied Research Network. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study
- Moler Fw
- K Meert
- Donaldson
- Ae
Moler FW, Meert K, Donaldson AE, et al.; Pediatric Emergency Care Applied Research Network. In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med. 2009;37: 2259–2267.
Red Iberoamericana de Estudio de la Parada Cardiorrespiratoria en la Infancia. Resuscitation training in developing countries: importance of a stable program of formation of instructors
- J López-Herce
- Urbano J Carrillo
López-Herce J, Urbano J, Carrillo A, et al.; Red Iberoamericana de Estudio
de la Parada Cardiorrespiratoria en la Infancia. Resuscitation training in
developing countries: importance of a stable program of formation of
instructors. Resuscitation. 2011;82:780.
In-hospital Pediatric Cardiac Arrest in Honduras
Pediatric Emergency Care • Volume 31, Number 1, January 2015
In-hospital Pediatric Cardiac Arrest in Honduras