Clinical and Electroencephalographic Correlates in Pediatric Cardiac Arrest: Experience at a Tertiary Care Center

AbstractPediatric cardiac arrest is a significant cause of death and neurologic disability; however, there is a paucity of literature specifically evaluating the utility of prognostic factors in the pediatric population. This retrospective chart review examines clinical, laboratory, and electroencephalographic (EEG) data in children following cardiopulmonary arrest to better characterize findings that may inform prognosis. Pre-arrest clinical characteristics, resuscitation details, and post-arrest hospital course variables were analyzed and neurologic outcome was determined using the Pediatric Cerebral Performance Category scale. Forty-one patients were identified who had cardiac arrest from March, 2011 to January, 2015. Duration of cardiopulmonary resuscitation (p = 0.013), out-of-hospital arrest (p = 0.005), arterial pH (0.014), arterial lactate (0.004), lack of pupil reactivity to light (p < 0.001), absent motor response to noxious stimuli (p < 0.001), and absent brainstem reflexes (p < 0.001) were all predictors of poor neurologic outcome. EEG background suppression (p = 0.005) was associated with poor outcome. Nine patients had electrographically recorded seizures, which began up to 1 week following cardiac arrest. Two patients (4.9%) experienced post-anoxic myoclonic status epilepticus and both had a poor outcome.

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Growth differentiation factor 15 and early prognosis after out-of-hospital cardiac arrest

Annals of Intensive Care ◽

10.1186/s13613-019-0593-9 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 1

Author(s):

Ferran Rueda ◽

Germán Cediel ◽

Cosme García-García ◽

Júlia Aranyó ◽

Marta González-Lopera ◽

...

Keyword(s):

Cardiac Arrest ◽

Tissue Injury ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Home Setting ◽

Growth Differentiation Factor 15 ◽

Poor Outcome ◽

Differentiation Factor ◽

Hospital Cardiac Arrest ◽

Early Predictor

Abstract Background Growth differentiation factor 15 (GDF-15) is an inflammatory cytokine released in response to tissue injury. It has prognostic value in cardiovascular diseases and other acute and chronic conditions. Here, we explored the value of GDF-15 as an early predictor of neurologic outcome after an out-of-hospital cardiac arrest (OHCA). Methods Prospective registry study of patients in coma after an OHCA, admitted in the intensive cardiac care unit from a single university center. Serum levels of GDF-15 were measured on admission. Neurologic status was evaluated according to the cerebral performance category (CPC) scale. The relationship between GDF-15 levels and poor neurologic outcome at 6 months was analyzed. Results Among 62 patients included, 32 (51.6%) presented poor outcome (CPC 3–5). Patients with CPC 3–5 exhibited significantly higher GDF-15 levels (median, 17.1 [IQR, 11.1–20.4] ng/mL) compared to those with CPC 1–2 (7.6 [IQR, 4.1–13.1] ng/mL; p = 0.004). Multivariable logistic regression analyses showed that age (OR, 1.09; 95% CI 1.01–1.17; p = 0.020), home setting arrest (OR, 8.07; 95% CI 1.61–40.42; p = 0.011), no bystander cardiopulmonary resuscitation (OR, 7.91; 95% CI 1.84–34.01; p = 0.005), and GDF-15 levels (OR, 3.74; 95% CI 1.32–10.60; p = 0.013) were independent predictors of poor outcome. The addition of GDF-15 in a dichotomous manner (≥ 10.8 vs. < 10.8 ng/mL) to the resulting clinical model improved discrimination; it increased the area under the curve from 0.867 to 0.917, and the associated continuous net reclassification improvement was 0.90 (95% CI 0.48–1.44), which allowed reclassification of 37.1% of patients. Conclusions After an OHCA, increased GDF-15 levels were an independent, early predictor of poor neurologic outcome. Furthermore, when added to the most common clinical factors, GDF-15 improved discrimination and allowed patient reclassification.

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Profile and outcome of pediatric intussusception: a 5-year experience in a tertiary care center

Annals of Pediatric Surgery ◽

10.1186/s43159-021-00097-5 ◽

2021 ◽

Vol 17 (1) ◽

Author(s):

Aqeela J. Madan ◽

Fayza Haider ◽

Saeed Alhindi

Keyword(s):

Seasonal Variation ◽

Success Rate ◽

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Operative Intervention ◽

Secondary Outcome ◽

Lead Point ◽

Pneumatic Reduction ◽

Tertiary Center

Abstract Background Intussusception is the most frequent cause of bowel obstruction in infants and toddlers; idiopathic intussusception occurs predominantly under the age of 3 and is rare after the age of 6 years; the highest incidence occurs in infants between 4 and 9 months; the gold standard for treatment of intussusception is non-operative reduction. This research will tackle the problem of pediatric intussusception in our center which is the largest tertiary center in our region. The primary outcome is to study the profile of intussusception; the secondary outcome is to assess the success rate of pneumatic reduction in the center’s pediatric population as well as to study the seasonal variation if present. Results During the study period, eighty-six (N=86) cases were identified, from which 10 cases were recurrent intussusception. Seventy-six (N=76) cases were included from the study period. N=68 (89%) were less than 3 years of age, and only N=2 (3%) were above 6 years. Seasonal variation was not significant; N=69 (91%) patients had successful pneumatic reduction under fluoroscopy while thirteen patients N=13 (17%) needed operative intervention. Conclusion Ileocolic intussusception is one of the most common pediatric surgical emergencies that can be successfully managed non-operatively in our institute; 89% of the cases were below 3 years of age, and no seasonal variation was demonstrated. Operative intervention was required in 13 cases with the main reason being lead point. The fact that the pediatric surgeon performs the reduction might have contributed to a high success rate reaching 91% in our center. This study provides a valuable opportunity for future regional data comparisons and pooled data analyses.

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Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Scientific Reports ◽

10.1038/s41598-020-79283-1 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Yo Sep Shin ◽

Youn-Jung Kim ◽

Seung Mok Ryoo ◽

Chang Hwan Sohn ◽

Shin Ahn ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Low Flow ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Neurologic Status ◽

Good Neurologic Outcome ◽

Hospital Stays ◽

Hospital Cardiac Arrest

AbstractPrecise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

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Accidental tramadol ingestion in children admitted in tertiary care centre

International Journal of Basic & Clinical Pharmacology ◽

10.18203/2319-2003.ijbcp20195200 ◽

2019 ◽

Vol 8 (12) ◽

pp. 2661

Author(s):

Vadlakonda Sruthi ◽

Annaladasu Narendra

Keyword(s):

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Ventilatory Support ◽

Case Series ◽

Pediatric Intensive Care ◽

Hemodynamic Instability ◽

Tertiary Care Centre ◽

Medical College ◽

History Of

Background: Tramadol use has been increasing in the adult and pediatric population. Practitioners must be alert because Tramadol misuse can lead to severe intoxication in which respiratory failure and seizures are frequent. Overdoses can lead to death. We report 47 pediatric cases with history of accidental tramadol exposure in children.Methods: An observational, retrospective, single center case -series of children with a history of accidental tramadol exposure in children admitted in pediatric intensive care unit of tertiary care center, Niloufer Hospital (Osmania Medical College) Hyderabad, Telangana India.Results: Of 47 children, 22 (47%) are male and 25 (53%) were female. At presentation 11 (23%) had loss of consciousness, 14 (29%) seizures, 17 (36%) hypotonia was noted. Pupils were miotic in 22 (47%) mydriatic in 2 (4.2%) normal in rest of children. Hemodynamic instability noted in 13 (27.6%). Serotonin syndrome (tachycardia, hyperthermia, hypertension, hyper reflex, clonus) was noted on 5 (10.6%) children. Respiratory depression was seen in 4 (8%) children who needed ventilatory support. Antidote Naloxone was given in 7 children. No adverse reaction was noted with Naloxone. All 47 children were successfully discharged.Conclusions: Overdoses can lead to death and practitioners must be alert because of the increasing use of tramadol in the adult and pediatric population. The handling of the tramadol should be explained to parents and general population and naloxone could be efficient when opioid toxicity signs are present.

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A Practical Risk-Score for Early Prediction of Neurological Outcome after Out-of-Hospital Cardiac Arrest –MIRA2CLE2

10.1101/2020.04.12.20045146 ◽

2020 ◽

Author(s):

Nilesh Pareek ◽

Peter Kordis ◽

Nicholas Beckley-Hoelscher ◽

Dominic Pimenta ◽

Spela Tadel Kocjancic ◽

...

Keyword(s):

Cardiac Arrest ◽

Risk Score ◽

Neurological Outcome ◽

Heart Attack ◽

Primary Outcome ◽

Cerebral Performance Category ◽

Epinephrine Administration ◽

Poor Outcome ◽

Poor Neurological Outcome ◽

Hospital Cardiac Arrest

AimsThe purpose of this study was to develop a practical risk−score to predict poor neurological outcome after out−of−hospital cardiac arrest (OOHCA) for use on arrival to a Heart Attack Centre.Methods and ResultsBetween May 2012 and December 2017, 1055 patients had OOHCA in our region, of whom 373 patients were included in the King's Out of Hospital Cardiac Arrest Registry (KOCAR). We performed prediction modelling with multi-variable logistic regression to identify factors independently predictive of the primary outcome in order to derive a risk score. This was externally validated in two independent cohorts comprising 474 patients. The primary outcome was poor neurological function at 6−month follow−up (Cerebral Performance Category 3-−). Seven independent variables for prediction of outcome were identified: Missed (Unwitnessed) arrest, Initial non-shockable rhythm, non-Reactivity of pupils, Age, Changing intra-arrest rhythms, Low pH<;7.20 and Epinephrine administration. From these variables, the MIRA2CLE2 score was developed which had an AUC of 0.90 in the development and 0.85 and 0.89 in the validation cohorts. 3 risk groups of the MIRA2CLE2 were defined − Low risk (≤2−5.6% risk of poor outcome; Intermediate risk (3−4−55.4% of poor outcome) and high risk (≥5−92.3% risk of poor outcome). The risk-score performance was equivalent in a sub-group of patients referred for early angiography and revascularisation where appropriate.ConclusionsThe MIRA2CLE2 score is a practical risk score for early accurate prediction of poor neurological outcome after OOHCA, which has been developed for simplicity of use on admission to a Heart Attack Centre.

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Abstract 113: Signs of Perfusion During Cardiopulmonary Resuscitation as Noted by First Responders is Predictive of Good Neurologic Outcome in Cardiac Arrest

Circulation ◽

10.1161/circ.138.suppl_2.113 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Johanna C Moore ◽

Michael Grahl ◽

Tracy Marko ◽

Ariel Blythe-Reske ◽

Amber Lage ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Life Support ◽

Cerebral Performance Category ◽

First Responders ◽

Small Sample ◽

Neurologic Outcome ◽

Discharge Data ◽

Good Neurologic Outcome ◽

Neurologically Intact

Background: Rates of neurologically intact survival after cardiac arrest remain abysmal. Neuro-prognostication intra-arrest is challenging, with few real-time factors that can be used to determine patient prognosis. During the implementation of a new cardiopulmonary resuscitation (CPR) protocol in a large urban pre-hospital system, first responders prospectively recorded the presence of signs of perfusion during CPR. Hypothesis: Positive signs of perfusion would be a predictor of a good neurologic outcome in this observational study, as defined by Cerebral Performance Category (CPC) Score of 1 or 2. Methods: Basic life support first responders (n = 420) and paramedics (n = 207) underwent training including didactic and hands-on sessions to learn the new protocol, which included active compression-decompression CPR with an impedance threshold device. In addition to patient demographics and circumstances of cardiac arrest, signs of perfusion during CPR were prospectively recorded and included improved color, pulse during CPR, gasping, and movement during CPR. Chart review was performed to determine CPC score at discharge. Data were analyzed using descriptive statistics and calculation of unadjusted odds ratios. Results: The new protocol began May 1, 2017. Cases from May 2017-November 2017 (n= 102) were reviewed, with complete data available for 96 patients (94%). The median age was 56 (range 25-97), 54/91 (59%) male, 43/102 (42%) witnessed, 31/90 (34%) shockable rhythm, and 51/102 (50%) receiving bystander CPR. Improved color during CPR was seen in 23/102 (23%), pulse during CPR in 17/102 (17%), gasping in 18/102 (18%), and movement during CPR in 5/102 (5%). Any sign of perfusion during CPR was seen in 47/102 (46%), and 13/96 (13.5%) had a CPC score of 1 or 2 at discharge. The unadjusted OR for any sign of perfusion during CPR for a CPC score of 1 or 2 was 26 (95% CI 3 - 213) and for any sign of perfusion during CPR for ROSC was 9 (95% CI 3 - 24). Conclusions: Positive signs of perfusion during CPR noted by first responders strongly predicted ROSC and neurologically intact survival in this small sample. This suggests the importance of prospectively recording signs of perfusion during resuscitation, and communicating these observations during transfer of care.

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Abstract 01: The Importance of Time to Cooling in Out-Of-Hospital Cardiac Arrest Patients to Influence Neurologically Intact Survival: A Sub-Analysis of the Princess Trial

Circulation ◽

10.1161/circ.140.suppl_2.01 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Akil Awad ◽

Fabio Silvio Taccone ◽

Martin Jonsson ◽

Sune Forsberg ◽

Jacob Hollenberg ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score ◽

Life Support ◽

Cerebral Performance Category ◽

Neurologic Outcome ◽

Secondary Outcome ◽

Control Group ◽

Shockable Rhythm ◽

Good Neurologic Outcome ◽

Hospital Cardiac Arrest

Background: Early initiation of hypothermia has shown to be important to reduce brain injuries in experimental cardiac arrest models. The aim of this study was to investigate the association between time to initiate cooling and neurological intact survival in patients with out-of-hospital cardiac arrest (OHCA). Methods: A secondary analysis of prospectively collected data from the PRINCESS trial (NCT01400373) including 677 OHCA patients randomized to transnasal evaporative intra-arrest cooling or standard advanced life support and cooling started subsequent to hospital arrival. Time to randomization was used a proxy measurement for time to initiate cooling. An early treatment group was defined as patients randomized by the EMS <20 minutes from the time of the cardiac arrest. Propensity scores were used to find matching patients in the control group. Patients with initial shockable rhythms were analyzed as a predefined subgroup. The primary outcome was good neurologic outcome, Cerebral Performance Category (CPC) 1-2 at 90 days. Secondary outcome was complete recovery (CPC 1). Results: In total 406 patients were randomized <20 minutes from the cardiac arrest and were propensity score matched (1:1). In the propensity score matched analysis the proportion of patients with CPC 1-2 was 21.7% in the intervention and 17.2% in the control group, odds ratio (OR) 1.33, 95% confidence interval (CI) 0.80-2.21, p=0.273. In patients with initial shockable rhythm (79 intervention, 79 control) the difference in CPC 1-2 was 48.1% versus 32.0%, OR 2.05, 95%CI 1.00-4.21, p=0.0498. The proportion of patients with complete neurologic recovery, CPC 1, was 19.7% in the intervention and 13.3% in the control group, OR 1.60, 95% CI 0.92-2.79, p=0.097. In patients with initial shockable rhythm the proportion with CPC 1 was 45.6% versus 24.6%, OR 2.81, 95% CI 1.23-6.42, p=0.014. Conclusions: In this ancillary study of OHCA patients receiving intra-arrest cooling, there were differences in survival with good neurologic outcome and in complete neurological recovery in favor of early intra-arrest cooling patient group compared to standard care. These differences were statistically significant in the subgroup of patients with initial shockable rhythms.

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Abstract 307: The Value of Intracranial Pressure Measurement via Lumbar Puncture as an Early Prognostic Predictor in Cardiac Arrest Patients Treated With Targeted Temperature Management

Circulation ◽

10.1161/circ.138.suppl_2.307 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Yeonho You ◽

Jung Soo Park ◽

Jin Hong Min

Keyword(s):

Cardiac Arrest ◽

Lumbar Puncture ◽

Brain Injuries ◽

Roc Curves ◽

Neurologic Outcome ◽

Temperature Management ◽

Significance Level ◽

Poor Outcome ◽

Neurologic Outcomes ◽

Outcome Group

Introduction: We evaluated prognostic value of ICP measurement via lumbar puncture to predict outcome of cardiac arrest patients treated with TTM Methods: This was a single-center observational cohort study using paper sheets of patients from October 2012 to June 2017. The primary endpoint was the ability of the early ICP measurement to predict poor outcome within 24 h after cardiac arrest, compared to ONSD and GWR. Based on previous studies, 32 patients were needed to achieve the power of 0.90 at a significance level of 0.05. The ROC curves was used to compare the values of ONSD, GWR and ICP for predicting neurologic outcomes. Results were considered significant at P < 0.05. Results: 103 patients were enrolled and good outcome group had 31 patients, while poor outcome group had 72 patients. The AUROC of ONSD and GWR were 0.64(0.54-0.73) and 0.63 (0.53-0.72) respectively in predicting poor neurologic outcome while the AUROC of ICP was 0.97(0.92-0.99) in predicting poor neurologic outcome (Fig. 2). As the cut off value of ICP was 200 mmH 2 O, sensitivity was 87.50% and specificity was 100.00% in predicting poor neurologic outcome. In ONSD, sensitivity was 78.43% and specificity was 41.86% in predicting poor neurologic outcome when cut off value was 5.50 mm. As the cut off value of GWR was 1.16, sensitivity was 59.72% and specificity was 74.19% in predicting poor neurologic outcome. Conclusion: In this study, we confirms that ICP measurement via lumbar puncture within the first 24 h after cardiac arrest is a valuable tool to evaluate the severity of post-cardiac arrest brain injuries and outcome in patients treated with TTM.

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Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocy034 ◽

2018 ◽

Vol 25 (7) ◽

pp. 848-854 ◽

Cited By ~ 8

Author(s):

Kimberly Whalen ◽

Emily Lynch ◽

Iman Moawad ◽

Tanya John ◽

Denise Lozowski ◽

...

Keyword(s):

Electronic Health Record ◽

Medication Safety ◽

Pediatric Population ◽

Care Center ◽

Tertiary Care ◽

Lessons Learned ◽

Future Research ◽

Health Record ◽

Electronic Health ◽

Roll Out

Abstract Objective While the electronic health record (EHR) has become a standard of care, pediatric patients pose a unique set of risks in adult-oriented systems. We describe medication safety and implementation challenges and solutions in the pediatric population of a large academic center transitioning its EHR to Epic. Methods Examination of the roll-out of a new EHR in a mixed neonatal, pediatric and adult tertiary care center with staggered implementation. We followed the voluntarily reported medication error rate for the neonatal and pediatric subsets and specifically monitored the first 3 months after the roll-out of the new EHR. Data was reviewed and compiled by theme. Results After implementation, there was a 5-fold increase in the overall number of medication safety reports; by the third month the rate of reported medication errors had returned to baseline. The majority of reports were near misses. Three major safety themes arose: (1) enterprise logic in rounding of doses and dosing volumes; (2) ordering clinician seeing a concentration and product when ordering medications; and (3) the need for standardized dosing units through age contexts created issues with continuous infusions and pump library safeguards. Conclusions Future research and work need to be focused on standards and guidelines on implementing an EHR that encompasses all age contexts.

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Renal Insufficiency and Early Bystander CPR Predict In-Hospital Outcomes in Cardiac Arrest Patients Undergoing Mild Therapeutic Hypothermia and Cardiac Catheterization: Return of Spontaneous Circulation, Cooling, and Catheterization Registry (ROSCCC Registry)

Cardiology Research and Practice ◽

10.1155/2016/8798261 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

Anjala Chelvanathan ◽

David Allen ◽

Hilary Bews ◽

John Ducas ◽

Kunal Minhas ◽

...

Keyword(s):

Cardiac Arrest ◽

Renal Insufficiency ◽

Hospital Mortality ◽

Therapeutic Hypothermia ◽

Cardiac Catheterization ◽

Tertiary Care ◽

Mild Therapeutic Hypothermia ◽

Neurologic Outcome ◽

Critically Ill Patient ◽

Bystander Cpr

Objective.Out of hospital cardiac arrest (OHCA) patients are a critically ill patient population with high mortality. Combining mild therapeutic hypothermia (MTH) with early coronary intervention may improve outcomes in this population. The aim of this study was to evaluate predictors of mortality in OHCA patients undergoing MTH with and without cardiac catheterization.Design.A retrospective cohort of OHCA patients who underwent MTH with catheterization (MTH + C) and without catheterization (MTH + NC) between 2006 and 2011 was analyzed at a single tertiary care centre. Predictors of in-hospital mortality and neurologic outcome were determined.Results.The study population included 176 patients who underwent MTH for OHCA. A total of 66 patients underwent cardiac catheterization (MTH + C) and 110 patients did not undergo cardiac catheterization (MTH + NC). Immediate bystander CPR occurred in approximately half of the total population. In the MTH + C and MTH + NC groups, the in-hospital mortality was 48% and 78%, respectively. The only independent predictor of in-hospital mortality for patients with MTH + C, after multivariate analysis, was baseline renal insufficiency (OR = 8.2, 95% CI 1.8–47.1, andp= 0.009).Conclusion.Despite early cardiac catheterization, renal insufficiency and the absence of immediate CPR are potent predictors of death and poor neurologic outcome in patients with OHCA.

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