RESUMEN

OBJECTIVES: To validate a computational phenotype that identifies acute brain dysfunction (ABD) based on clinician concern for neurologic or behavioral changes in pediatric sepsis. DESIGN: Retrospective observational study. SETTING: Single academic children's hospital. PATIENTS: Four thousand two hundred eighty-nine index sepsis episodes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: An existing computational phenotype of ABD was optimized to include routinely collected variables indicative of clinician concern for acute neurologic or behavioral change (completion of CT or MRI, electroencephalogram, or new antipsychotic administration). First, the computational phenotype was compared with an ABD reference standard established from chart review of 527 random sepsis episodes to determine criterion validity. Next, the computational phenotype was compared with a separate validation cohort of 3,762 index sepsis episodes to determine content and construct validity. Criterion validity for the final phenotype had sensitivity 83% (95% CI, 76-89%), specificity 93% (90-95%), positive predictive value 84% (77-89%), and negative predictive value 93% (90-96%). In the validation cohort, the computational phenotype identified ABD in 35% (95% CI 33-36%). Content validity was demonstrated as those with the ABD computational phenotype were more likely to have characteristics of neurologic dysfunction and severe illness than those without the ABD phenotype, including nonreactive pupils (15% vs 1%; p < 0.001), Glasgow Coma Scale less than 5 (44% vs 12%; p < 0.001), greater than or equal to two nonneurologic organ dysfunctions (50% vs 25%; p < 0.001), and need for intensive care (81% vs 65%; p < 0.001). Construct validity was demonstrated by higher odds for mortality (odds ratio [OR], 6.9; 95% CI, 5.3-9.1) and discharge to rehabilitation (OR, 11.4; 95% CI 7.4-17.5) in patients with, versus without, the ABD computational phenotype. CONCLUSIONS: A computational phenotype of ABD indicative of clinician concern for new neurologic or behavioral change offers a valid retrospective measure to identify episodes of sepsis that involved ABD. This computational phenotype provides a feasible and efficient way to study risk factors for and outcomes from ABD using routinely collected clinical data.

Asunto(s)

Encefalopatías , Sepsis , Humanos , Estudios Retrospectivos , Mortalidad Hospitalaria , Sepsis/diagnóstico , Encefalopatías/diagnóstico , Encefalopatías/etiología , Fenotipo , Encéfalo/diagnóstico por imagen

Asunto(s)

Paro Cardíaco , Hipotermia Inducida , Niño , Paro Cardíaco/terapia , Humanos , Calidad de Vida

RESUMEN

OBJECTIVES: While most pediatric coronavirus disease 2019 cases are not life threatening, some children have severe disease requiring emergent resuscitative interventions. Resuscitation events present risks to healthcare provider safety and the potential for compromised patient care. Current resuscitation practices and policies for children with suspected/confirmed coronavirus disease 2019 are unknown. DESIGN: Multi-institutional survey regarding inpatient resuscitation practices during the coronavirus disease 2019 pandemic. SETTING: Internet-based survey. SUBJECTS: U.S. PICU representatives (one per institution) involved in resuscitation system planning and oversight. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 130 institutions surveyed, 78 (60%) responded. Forty-eight centers (62%) had admitted coronavirus disease 2019 patients; 26 (33%) reported code team activation for patients with suspected/confirmed coronavirus disease 2019. Sixty-seven respondents (86%) implemented changes to inpatient emergency response systems. The most common changes were as follows: limited number of personnel entering patient rooms (75; 96%), limited resident involvement (71; 91%), and new or refined team roles (74; 95%). New or adapted technology is being used for coronavirus disease 2019 resuscitations in 58 centers (74%). Most institutions (57; 73%) are using enhanced personal protective equipment for all coronavirus disease 2019 resuscitation events; 18 (23%) have personal protective equipment policies dependent on the performance of aerosol generating procedures. Due to coronavirus disease 2019, most respondents are intubating earlier during cardiopulmonary resuscitation (56; 72%), utilizing video laryngoscopy (67; 86%), pausing chest compressions during laryngoscopy (56; 72%), and leaving patients connected to the ventilator during cardiopulmonary resuscitation (56; 72%). Responses were varied regarding airway personnel, prone cardiopulmonary resuscitation, ventilation strategy during cardiopulmonary resuscitation without an airway in place, and extracorporeal cardiopulmonary resuscitation. Most institutions (46; 59%) do not have policies regarding limitations of resuscitation efforts in coronavirus disease 2019 patients. CONCLUSIONS: Most U.S. pediatric institutions rapidly adapted their resuscitation systems and practices in response to the coronavirus disease 2019 pandemic. Changes were commonly related to team members and roles, personal protective equipment, and airway and breathing management, reflecting attempts to balance quality resuscitation with healthcare provider safety.

Asunto(s)

Reanimación Cardiopulmonar/métodos , Infecciones por Coronavirus/epidemiología , Paro Cardíaco/terapia , Hospitales , Pandemias , Neumonía Viral/epidemiología , Manejo de la Vía Aérea/métodos , Betacoronavirus , COVID-19 , Niño , Infecciones por Coronavirus/terapia , Humanos , Unidades de Cuidado Intensivo Pediátrico , Neumonía Viral/terapia , Guías de Práctica Clínica como Asunto , SARS-CoV-2 , Encuestas y Cuestionarios , Estados Unidos

RESUMEN

OBJECTIVES: Postcardiac arrest care bundles following adult cardiac arrest are associated with improved survival to discharge. We aimed to evaluate whether a clinical pathway and computerized order entry were associated with improved pediatric postcardiac arrest care and discharge outcomes. DESIGN: Single-center retrospective before-after study. SETTING: Academic PICU. PATIENTS: Patients who suffered an in- or out-of-hospital cardiac arrest from January 2008 to December 2015 cared for in the PICU within 12 hours of sustained return of circulation. INTERVENTION: Deployment of a postcardiac arrest clinical pathway and computerized order entry system. MEASUREMENTS AND MAIN RESULTS: There were 380 patients included-163 in the pre-pathway period and 217 in the post-pathway period. Primary outcome was percent adherence to pathway clinical goals at 0-6 and 6-24 hours post-return of circulation and to diagnostics (continuous electroencephalogram monitoring, head CT for out-of-hospital cardiac arrests, echocardiogram). Secondary outcomes included survival to hospital discharge and survival with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). The pre-pathway and post-pathway groups differed in their baseline Pediatric Cerebral Performance Category scores and the following causes of arrest: airway obstruction, arrhythmias, and electrolyte abnormalities. Pathway adherence was not significantly different between the pre-pathway and post-pathway groups, with the exception of higher rates of continuous electroencephalogram monitoring (45% vs 64%; p < 0.001). There was no difference in survival to hospital discharge between the two groups (56% vs 67%; adjusted odds ratio, 1.68; 95% CI, 0.95-2.84; p = 0.05). Survival to discharge was higher in the post-pathway group for the in-hospital cardiac arrest cohort (55% vs 76%; adjusted odds ratio, 3.06; 95% CI, 1.44-6.51; p < 0.01). There was no difference in favorable neurologic outcome between all patients (adjusted odds ratio, 1.21; 95% CI, 0.72-2.04) or among survivors (adjusted odds ratio, 0.72; 95% CI, 0.27-1.43). CONCLUSIONS: After controlling for known potential confounders, the creation and deployment of a postcardiac arrest care pathway and computerized order entry set were not associated with improvement in pathway adherence or overall outcomes, but was associated with increased survival to hospital discharge for children with in-hospital cardiac arrests.

Asunto(s)

Reanimación Cardiopulmonar , Paro Cardíaco Extrahospitalario , Adulto , Niño , Estudios Controlados Antes y Después , Vías Clínicas , Humanos , Paro Cardíaco Extrahospitalario/terapia , Estudios Retrospectivos , Resultado del Tratamiento

Asunto(s)

Unidades de Cuidado Intensivo Pediátrico , Convulsiones , Niño , Electroencefalografía , Humanos

Asunto(s)

Electroencefalografía , Paro Cardíaco , Niño , Humanos , Lactante , Monitoreo Fisiológico , Pronóstico

RESUMEN

OBJECTIVES: In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes. DESIGN: Retrospective single-center cohort study. SETTING: PICU of a quaternary care, academic children's hospital. PATIENTS: Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85). CONCLUSIONS: Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.

Asunto(s)

Reanimación Cardiopulmonar , Paro Cardíaco , Hipertensión Pulmonar , Adulto , Niño , Estudios de Cohortes , Paro Cardíaco/epidemiología , Paro Cardíaco/etiología , Paro Cardíaco/terapia , Humanos , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/epidemiología , Prevalencia , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

OBJECTIVES: To evaluate the association of a single episode of hypotension and burden of hypotension with survival to hospital discharge following resuscitation from pediatric cardiac arrest. DESIGN: Retrospective cohort study. SETTING: Single-center PICU. PATIENTS: Patients between 1 day and 18 years old who had a cardiac arrest, received chest compressions for more than 2 minutes, had return of spontaneous circulation for more than 20 minutes, and survived to receive postresuscitation care in the ICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: One-hundred sixteen patients were evaluable. Hypotension, defined as systolic blood pressure less than the fifth percentile for age and sex, occurred in 37 patients (32%) within the first 6 hours and 64 (55%) within 72 hours of postresuscitation ICU care. There was no significant difference in survival to discharge for patients who had a single episode of hypotension within 6 hours (51% vs 69%; p = 0.06) or within 72 hours (56% vs 73%; p = 0.06). Burden of hypotension was defined as the percentage of hypotension measurements that were below the fifth percentile. After controlling for patient and cardiac arrest event characteristics, a higher burden of hypotension within the first 72 hours of ICU postresuscitation care was associated with decreased discharge survival (adjusted odds ratio = 0.67 per 10% increase in hypotension burden; 95% CI, 0.48-0.86; p = 0.006). CONCLUSIONS: After successful resuscitation from pediatric cardiac arrest, systolic hypotension was common (55%). A higher burden of postresuscitation hypotension within the first 72 hours of ICU postresuscitation care was associated with significantly decreased discharge survival, after accounting for potential confounders including number of doses of epinephrine, arrest location, and arrest etiology due to airway obstruction or trauma.

Asunto(s)

Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Hipotensión/mortalidad , Adolescente , Presión Sanguínea , Niño , Preescolar , Epinefrina/uso terapéutico , Femenino , Paro Cardíaco/mortalidad , Humanos , Hipotensión/epidemiología , Lactante , Masculino , Alta del Paciente , Estudios Retrospectivos , Tasa de Supervivencia

RESUMEN

OBJECTIVES: Pulmonary embolism is a rarely reported and potentially treatable cause of cardiac arrest in children and adolescents. The objective of this case series is to describe the course of five adolescent patients with in-hospital cardiac arrest secondary to pulmonary embolism. DESIGN: Case series. SETTING: Single, large academic children's hospital. PATIENTS: All patients under the age of 18 years (n = 5) who experienced an in-hospital cardiac arrest due to apparent pulmonary embolism from August 1, 2013, to July 31, 2017. INTERVENTIONS: All five patients received systemic thrombolytic therapy (IV tissue plasminogen activator) during cardiac arrest or periarrest during ongoing resuscitation efforts. MEASUREMENTS AND MAIN RESULTS: Five adolescent patients, 15-17 years old, were treated for pulmonary embolism-related cardiac arrests during the study period. These accounted for 6.3% of all children and 25% of adolescents (12-17 yr old) receiving at least 5 minutes of in-hospital cardiopulmonary resuscitation during the study period. All five had venous thromboembolism risk factors. Two patients had known, extensive venous thrombi at the time of cardiac arrest, and one was undergoing angiography at the time of arrest. The diagnoses of pulmonary embolism were based on clinical suspicion, bedside echocardiography (n = 4), and low end-tidal CO2 levels relative to arterial CO2 values (n = 5). IV tissue plasminogen activator was administered during cardiopulmonary resuscitation in three patients and after the return of spontaneous circulation, in the setting of severe hemodynamic instability, in the other two patients. Four of five patients were successfully resuscitated and survived to hospital discharge. CONCLUSIONS: Pulmonary embolism was recognized as the etiology of multiple adolescent cardiac arrests in this single-center series and may be more common than previously reported. Recognition, high-quality cardiopulmonary resuscitation, and treatment with thrombolytic therapy resulted in survival in four of five patients.

Asunto(s)

Paro Cardíaco/etiología , Embolia Pulmonar/complicaciones , Adolescente , Reanimación Cardiopulmonar , Niño , Angiografía por Tomografía Computarizada , Femenino , Paro Cardíaco/terapia , Hospitales Pediátricos , Humanos , Infusiones Intravenosas , Masculino , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/tratamiento farmacológico , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/uso terapéutico

RESUMEN

OBJECTIVES: Limited data exist on the effects of therapeutic hypothermia on renal function and pharmacokinetics in pediatric patients after cardiac arrest. The objective was to describe the differences in vancomycin disposition in pediatric patients following cardiac arrest treated with either therapeutic hypothermia or normothermia using population pharmacokinetic modeling. DESIGN: Single-center, retrospective cohort study. SETTING: A tertiary care hospital pediatric and cardiac ICU. PATIENTS: Fifty-two pediatric patients (30 d to 17 yr old) who experienced a cardiac arrest, received vancomycin, and were treated with therapeutic hypothermia (32-34°C) or normothermia (36.3-37.6°C) between January 1, 2010, and September 30, 2014, were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A two-compartment model with linear elimination, weight effects on clearance, intercompartmental clearance (Q), central volume of distribution (V1), and peripheral volume of distribution (V2) adequately described the data despite high variability due to the small sample size. The typical value of clearance in this study was 4.48 L/hr (0.19 L/hr/kg) for a normothermic patient weighing 70 kg and a glomerular filtration rate of 90 mL/min/1.73 m. Patients treated with normothermia but with reduced or poor renal function (≤ 90 mL/min/1.73 m) had up to an 80% reduction in vancomycin clearance compared to those with normal renal function (90-140 mL/min/1.73 m). Patients with normal renal function but treated with therapeutic hypothermia versus normothermia experienced up to 25% reduction in vancomycin clearance. Patients treated with therapeutic hypothermia and with poor renal function experienced up to an 84% reduction in vancomycin clearance. CONCLUSIONS: Patients receiving hypothermia and/or with decreased renal function had lower vancomycin clearances based on a retrospectively fitted two-compartment model in children who experience cardiac arrest.

Asunto(s)

Antibacterianos/farmacocinética , Cuidados Críticos/métodos , Paro Cardíaco/terapia , Hipotermia Inducida , Resucitación/métodos , Vancomicina/farmacocinética , Adolescente , Antibacterianos/uso terapéutico , Temperatura Corporal , Peso Corporal , Niño , Preescolar , Terapia Combinada , Femenino , Paro Cardíaco/metabolismo , Humanos , Lactante , Riñón/fisiología , Masculino , Tasa de Depuración Metabólica , Modelos Biológicos , Estudios Retrospectivos , Vancomicina/uso terapéutico

RESUMEN

OBJECTIVES: Determine the accuracy and confidence of critical care medicine providers to identify seizures using amplitude-integrated electroencephalography versus amplitude-integrated electroencephalography combined with color density spectral array electroencephalography (aEEG + CDSA). DESIGN: Tutorial and questionnaire. SETTING: PICU. SUBJECTS: Pediatric critical care providers (attendings, fellows, and nurses). INTERVENTIONS: A standardized powerpoint tutorial on amplitude-integrated electroencephalography and color density spectral array followed by classification of 100 amplitude-integrated electroencephalography images and 100 amplitude-integrated electroencephalography combined with color density spectral array as displaying seizures or not displaying seizures. MEASUREMENTS AND MAIN RESULTS: Electroencephalography tracings were obtained from children monitored with continuous electroencephalography after cardiac arrest. The gold standard for seizure identification was continuous electroencephalography interpretation by a pediatric electroencephalographer. The same electroencephalography tracings were used to generate images containing only amplitude-integrated electroencephalography or aEEG + CDSA. Twenty-three critical care medicine providers underwent a 30-minute tutorial on amplitude-integrated electroencephalography and color density spectral array interpretation. They were then asked to determine if there were seizures on 100 amplitude-integrated electroencephalography images and 100 aEEG + CDSA. Amplitude-integrated electroencephalography seizure detection sensitivity was 77% (95% CI, 73%-80%), specificity of 65% (95% CI, 62%-67%), negative predictive value of 88% (95% CI, 86%-90%), and positive predictive value of 46% (95% CI, 43%-49%). For aEEG + CDSA, sensitivity was 77% (95% CI, 74%-81%), specificity of 68% (95% CI, 66%-71%), negative predictive value of 89% (95% CI, 87%-90%), and positive predictive value of 49% (95% CI, 46%-52%). Sensitivity for status epilepticus detection was 77% (95% CI, 71%-82%) with amplitude-integrated electroencephalography and 75% (95% CI, 69%-81%) with aEEG + CDSA. The addition of color density spectral array to amplitude-integrated electroencephalography did not improve seizure detection. However, 87% of critical care medicine providers qualitatively felt that combining both modalities increased their ability to detect seizures. CONCLUSIONS: Amplitude-integrated electroencephalography and aEEG + CDSA offer reasonable sensitivity and negative predictive value for seizure detection by critical care medicine providers. aEEG + CDSA did not improve seizure detection over amplitude-integrated electroencephalography alone although critical care medicine providers felt more confident using both tools combined. Amplitude-integrated electroencephalography and color density spectral array require further evaluation as a tool for screening for seizures and should only be used in conjunction with professional continuous electroencephalography review.

Asunto(s)

Competencia Clínica , Cuidados Críticos/métodos , Electroencefalografía/métodos , Paro Cardíaco/complicaciones , Convulsiones/diagnóstico , Adolescente , Actitud del Personal de Salud , Niño , Preescolar , Humanos , Lactante , Recién Nacido , Convulsiones/etiología , Sensibilidad y Especificidad

RESUMEN

OBJECTIVES: To determine 1) whether early electroencephalographic background features were associated with survival and neurologic outcomes among children resuscitated from cardiac arrest and not treated with therapeutic hypothermia and 2) if addition of electroencephalographic background to commonly used clinical criteria is more predictive of outcome than clinical criteria alone. DESIGN: Retrospective study. SETTING: PICU and Cardiac ICUs of a tertiary children's hospital. PATIENTS: Patients resuscitated from in-hospital or out-of-hospital cardiac arrest who underwent clinically indicated electroencephalographic monitoring and were not treated with therapeutic hypothermia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One-hundred twenty-eight patients underwent electroencephalographic monitoring within 1 day of return of spontaneous circulation. Background category was normal in four subjects (3%), slow-disorganized in 58 subjects (45%), discontinuous-burst suppression in 24 subjects (19%) and attenuated-flat in 42 subjects (33%). Forty-six subjects (36%) had a reactive electroencephalography. Twenty subjects (15%) had a seizure during electroencephalographic monitoring. Absence of reactivity (p < 0.001) and seizures (p = 0.04) were associated with worse electroencephalographic background category. After controlling for covariates, for each incrementally worse background score, the odds of death was 3.63 (95% CI, 2.18-6.0; p < 0.001) and the odds of unfavorable neurologic outcome was 4.38 (95% CI, 2.51-7.17; p = 0.001). CONCLUSIONS: Worse electroencephalographic background early after resuscitation from both in-hospital and out-of-hospital cardiac arrest is associated with increased odds of death and unfavorable neurologic outcomes at hospital discharge. These electroencephalographic background patterns may be used in addition to clinical criteria to support prognostic decision making.

Asunto(s)

Reanimación Cardiopulmonar , Técnicas de Apoyo para la Decisión , Electroencefalografía , Paro Cardíaco/diagnóstico , Paro Cardíaco/fisiopatología , Adolescente , Niño , Preescolar , Femenino , Paro Cardíaco/mortalidad , Paro Cardíaco/terapia , Humanos , Lactante , Recién Nacido , Masculino , Pronóstico , Estudios Retrospectivos , Convulsiones/diagnóstico , Convulsiones/etiología

Asunto(s)

Estado de Salud , Paro Cardíaco/complicaciones , Paro Cardíaco/psicología , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Calidad de Vida , Femenino , Humanos , Masculino

RESUMEN

OBJECTIVES: To characterize the association of hospital discharge survival with left ventricular systolic function evaluated by transthoracic echocardiography and vasoactive infusion support following return of spontaneous circulation after pediatric out-of-hospital cardiac arrest. DESIGN: Retrospective case series. SETTING: Single-center tertiary care pediatric cardiac arrest and critical care referral center. PATIENTS: Consecutive out-of-hospital cardiac arrest patients less than 18 years surviving to PICU admission who had a transthoracic echocardiography obtained by the clinical team within 24 hours of admission from January 2006 to May 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-eight patients had a post-return of spontaneous circulation transthoracic echocardiography performed within 24 hours of admission. The median time from return of spontaneous circulation to echo was 6.5 hours (interquartile range, 4.7, 15.0 hr). Left ventricular systolic function was decreased in 24 of 58 patients (41%). The mortality rate was 67% (39 of 58). Thirty-six patients (62%) received vasoactive infusions at the time of transthoracic echocardiography, and increased vasopressor inotropic score was associated with increased mortality on univariate analysis (p < 0.001). After controlling for defibrillation, vasopressor inotropic score, and interaction between vasopressor inotropic score and left ventricular systolic function, decreased left ventricular systolic function was associated with increased mortality (odds ratio, 13.7; 95% CI, 1.54-122). CONCLUSIONS: In patients receiving transthoracic echocardiography within the first 24 hours following return of spontaneous circulation after pediatric out-of-hospital cardiac arrest, decreased left ventricular systolic function and vasopressor use were common. Decreased left ventricular systolic function was associated with increased mortality.

Asunto(s)

Mortalidad Hospitalaria , Paro Cardíaco Extrahospitalario/mortalidad , Vasoconstrictores/uso terapéutico , Función Ventricular Izquierda , Adolescente , Niño , Preescolar , Ecocardiografía , Femenino , Humanos , Lactante , Masculino , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Paro Cardíaco Extrahospitalario/tratamiento farmacológico , Paro Cardíaco Extrahospitalario/fisiopatología , Evaluación de Resultado en la Atención de Salud , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia

RESUMEN

OBJECTIVE: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events. DESIGN, SETTING, AND PATIENTS: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU. INTERVENTIONS: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers. MEASUREMENTS AND MAIN RESULTS: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for ≥ 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed "excellent cardiopulmonary resuscitation," prospectively defined as a chest compression depth ≥ 38 mm, rate ≥ 100/min, ≤ 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01). CONCLUSION: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

Asunto(s)

Reanimación Cardiopulmonar/educación , Reanimación Cardiopulmonar/métodos , Paro Cardíaco/terapia , Unidades de Cuidados Intensivos , Personal de Hospital/educación , Niño , Preescolar , Femenino , Humanos , Lactante , Capacitación en Servicio , Masculino , Cuerpo Médico de Hospitales , Personal de Enfermería en Hospital , Estudios Prospectivos , Mejoramiento de la Calidad , Terapia Respiratoria