Cardiopulmonary resuscitation: special considerations for infants and children with cardiac disease

AbstractPulseless cardiac arrest, defined as the cessation of cardiac mechanical activity, determined by unresponsiveness, apneoa, and the absence of a palpable central pulse, accounts for around one-twentieth of admissions to paediatric intensive care units, be they medical or exclusively cardiac. Such cardiac arrest is higher in children admitted to a cardiac as opposed to a paediatric intensive care unit, but the outcome of these patients is better, with just over two-fifths surviving when treated in the cardiac intensive care unit, versus between one-sixth and one-quarter of those admitted to paediatric intensive care units. Children who receive chest compressions for bradycardia with pulses have a significantly higher rate of survival to discharge, at 60%, than do those presenting with pulseless cardiac arrest, with only 27% surviving to discharge. This suggests that early resuscitation before the patient becomes pulseless, along with early recognition and intervention, are likely to improve outcomes. Recently published reports of in-hospital cardiac arrests in children can be derived from the multi-centric National Registry of Cardiopulmonary Resuscitation provided by the American Heart Association. The population is heterogeneous, but most arrests occurred in children with progressive respiratory insufficiency, and/or progressive circulatory shock. During the past 4 years at the Children’s Hospital of Philadelphia, 3.1% of the average 1000 annual admissions to the cardiac intensive care unit have received cardiopulmonary resuscitation. Overall survival of those receiving cardiopulmonary resuscitation was 46%. Survival was better for those receiving cardiopulmonary resuscitation after cardiac surgery, at 53%, compared with survival of 33% for pre-operative or non-surgical patients undergoing resuscitation. Clearly there is room for improvement in outcomes from cardiac resuscitation in children with cardiac disease. In this review, therefore, we summarize the newest developments in paediatric resuscitation, with an expanded focus upon the unique challenges and importance of anticipatory care in infants and children with cardiac disease.

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Abstract 11345: Resource Demands and the Incidence of Cardiopulmonary Resuscitation Within a Pediatric Cardiac Intensive Care Unit

Circulation ◽

10.1161/circ.130.suppl_2.11345 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Matthew K Bacon ◽

Stephanie J Conrad ◽

Brittney C Hatch ◽

John D Hughes ◽

Michelle K Terrell ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Arrest ◽

Critical Care ◽

Intensive Care ◽

Cardiopulmonary Resuscitation ◽

Cardiac Intensive Care Unit ◽

Delivery Of Care ◽

Cardiac Intensive Care ◽

Nurse Assignment ◽

Hospital Morbidity

Background: Econometric evidence suggests exponential declines in the ability to provide critical care services as variable demands exceed a relatively fixed supply of available critical care resources. We hypothesized that increasing demands upon resources within a pediatric cardiac intensive care unit (CICU) is also associated with increases in the incidence and rate of cardiopulmonary resuscitation. Methods and Results: Records from each twelve-hour nursing shift within an eighteen-bed pediatric CICU from 1 July 2010 through 30 April 2014 were retrospectively reviewed. There were 2716 reports available for review from 2769 shifts (97%). During the study period, there were 1,803 surgical and 1,215 medical admissions, accounting for a median census of 15 (interquartile range [IQR] 13-17) patients per shift, and a total of 20,269 patient days (40,538 patient-shifts) over the 44-month study period. Median bed capacity was 83% (IQR 72-94%), and median patient to nursing assignment ratio was 1.5 (IQR 1.4-1.6 patients per nurse assignment). Cardiac arrest (defined as administration of chest compressions) was identified in 138 occasions in 134 shifts, an arrest rate of 3.4 arrests per 1000 patient-shifts. Arrests were no more frequent during night versus day shifts (3.2 v. 3.6 per 1000 patient shifts, p=0.40), nor were they greater during weekend versus weekday shifts (2.9 v. 3.9 per 100 patient-shifts, p=0.14). There was a trend toward an increase in the incidence of cardiac arrest with patient to nurse assignment ratios of less than 1.5 (2.8 v. 3.9 arrests per 1000 patient shifts, p=0.06). Unit occupancy exceeding 85% was associated with a 45% greater rate of cardiac arrest (2.6 v 4.1 arrests per 1000 patient-shifts, 95%CI 0.3 to 2.6 increase, p=0.01). Conclusions: We report a significant increase in the incidence of cardiopulmonary resuscitation at times of greater resource consumption within a pediatric CICU as defined by unit capacity. Multi-institutional studies are necessary to identify generalizable organizational characteristics that may promote efficient allocation of resources and optimize delivery of care to a population of patients at greater risk for significant hospital morbidity.

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Effect of Separating Intensive Care Units on Physician Productivity: Comparison of Work Rvu Generation Between a Cardiac Intensive Care Unit and General Pediatric Intensive Care Unit

PEDIATRICS ◽

10.1542/peds.137.supplement_3.265a ◽

2016 ◽

Vol 137 (Supplement 3) ◽

pp. 265A-265A

Author(s):

Alexander M Cartron ◽

Anne Watson ◽

Venkat Shankar

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Intensive Care Units ◽

Pediatric Intensive Care Unit ◽

Pediatric Intensive Care ◽

Cardiac Intensive Care Unit ◽

Physician Productivity ◽

Cardiac Intensive Care

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Abstract 285: Resuscitation Practices of Cardiac Arrest in Children with Cardiac Disease in Cardiac Intensive Care Units Compared to Pediatric Intensive Care Units

Circulation ◽

10.1161/circ.142.suppl_4.285 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Tanya Perry ◽

Tia T Raymond ◽

Joanna Fishbein ◽

Michael G Gaies ◽

Todd Sweberg ◽

...

Keyword(s):

Cardiac Arrest ◽

Intensive Care ◽

Intensive Care Units ◽

Cardiac Disease ◽

Univariate Analysis ◽

Pediatric Intensive Care ◽

Heart Association ◽

Pediatric Intensive Care Units ◽

Achievement Measures ◽

Cardiac Intensive Care

Introduction: Hospitalized children with critical cardiac disease experience cardiac arrest more than any other disease type. Varying models are devoted to caring for this population, including pediatric intensive care units (PICU) and dedicated cardiac intensive care units (CICU). The process of CPR delivery has not been evaluated in CICUs in comparison to PICUs. Hypothesis: There will be no difference in cardiac arrest resuscitation practices between unit types. Methods: We analyzed patients <18 years from the American Heart Association Get with the Guidelines-Resuscitation database (GWTG-R) with an illness category of medical or surgical cardiac disease who received CPR in a CICU or PICU from 2014 to 2018. Events were assessed for compliance with GWTG-R achievement measures of time to first chest compressions ≤ 1 minute, time to IV/IO epinephrine ≤ 5 minutes, time to first shock ≤ 2 minutes for VF/pulseless VT first documented rhythm, and confirmation of endotracheal tube (ETT) placement in trachea. Results: CPR practices were evaluated on 866 patients, 687 CICU and 179 PICU (55% male and 65% neonatal). Surgical cardiac disease was present in 56%. Cardiac malformations were present in 81% (45% cyanotic 29% acyanotic). Pulseless arrest was the initial event in 41% with a shockable rhythm in 14%. Return of spontaneous circulation occurred in 86% and survival to hospital discharge in 58%. Univariate analysis comparing resuscitation practice is shown in Table 1. ECPR use was the only variable noted to be significantly different between units (CICU 22% vs PICU 6%, P<0.01). On multivariate analysis, there were no differences in GWTG-R achievement measures between ICU types for ETT placement confirmation, time to IV/IO epinephrine dose, time to first chest compression to first shock (P>0.05). Conclusion: Despite differences in infrastructure, process, and provider expertise, there were no differences in cardiac arrest resuscitation practice between CICUs and PICUs.

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Influence of cardiac arrest and SCAI shock stage on cardiac intensive care unit mortality

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.28854 ◽

2020 ◽

Vol 96 (7) ◽

pp. 1350-1359 ◽

Cited By ~ 8

Author(s):

Jacob C. Jentzer ◽

Timothy D. Henry ◽

Gregory W. Barsness ◽

Venu Menon ◽

David A. Baran ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Arrest ◽

Intensive Care ◽

Intensive Care Unit Mortality ◽

Cardiac Intensive Care Unit ◽

Cardiac Intensive Care

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Prognostic value of automated pupillometry: an unselected cohort from a cardiac intensive care unit

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619842004 ◽

2019 ◽

Vol 9 (7) ◽

pp. 779-787 ◽

Cited By ~ 5

Author(s):

Laust Obling ◽

Christian Hassager ◽

Charlotte Illum ◽

Johannes Grand ◽

Sebastian Wiberg ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Arrest ◽

Intensive Care ◽

Area Under The Curve ◽

Youden Index ◽

Cardiac Intensive Care Unit ◽

Infrared Pupillometry ◽

Cardiac Intensive Care ◽

Neurological Pupil Index ◽

Hospital Cardiac Arrest

Background: Patients admitted to a cardiac intensive care unit are often unconscious with uncertain prognosis. Automated infrared pupillometry for neurological assessment in the intensive care unit may provide early prognostic information. This study aimed to determine the prognostic value of automated pupillometry in different subgroups of patients in a cardiac intensive care unit with 30-day mortality as the primary endpoint and neurological outcome as the secondary endpoint. Methods: A total of 221 comatose patients were divided into three groups: out-of-hospital cardiac arrest, in-hospital cardiac arrest and others (i.e. patients with cardiac diagnoses other than cardiac arrest). Automated pupillometry was serially performed until discharge or death and pupil measurements were analysed using the neurological pupil index algorithm. We applied receiver operating characteristic curves in univariable and multivariable logistic regression models and a calculated Youden index identified neurological pupil index cut-off values at different specificities. Results: In out-of-hospital cardiac arrest patients higher neurological pupil index values were independently associated with lower 30-day mortality. The univariable model for 30-day mortality had an area under the curve of 0.87 and the multivariable model achieved an area under the curve of 0.94. The Youden index identified a neurological pupil index cut-off in out-of-hospital cardiac arrest patients of 2.40 for a specificity of 100%. For patients with in-hospital cardiac arrest and other cardiac diagnoses, we found no association between neurological pupil index values and 30-day mortality, and the univariable models showed poor predictive values. Conclusion: Automated infrared pupillometry has promising predictive value after out-of-hospital cardiac arrest, but poor predictive value in patients with in-hospital cardiac arrest or cardiac diagnoses unrelated to cardiac arrest. Our data suggest a possible neurological pupil index cut-off of 2.40 for poor outcome in out-of-hospital cardiac arrest patients.

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