Abstract 14218: Post-Cardiac Arrest Care Delivery Varies Widely Across Institutions Belonging to the PediRES-Q Collaborative

Introduction: Despite national pediatric post-cardiac arrest care (PCAC) guidelines to improve survival and neurological outcomes, there are limited studies describing PCAC delivery in pediatric institutions. The objective of this study was to describe reported PCAC delivery in pediatric institutions. We hypothesized that there would be variability in PCAC processes across institutions. Methods: An IRB-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution belonging to the international Pediatric Resuscitation Quality Improvement collaborative (PediRES-Q). Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data. Results: Twenty-four of 47 centers completed the survey (51%). Most respondents (58%) belonged to large centers (≥1000 annual PICU admissions). Two-third (67%) of centers reported using no specific selection criteria to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Smaller centers (<1000 annual PICU admissions) more frequently reported the use of attending-directed care for PCAC initiation/delivery (80%) versus larger centers (57%), p = 0.04. Common PCAC targets included temperature (96%), glucose (75%), and age-based blood pressure (88%). Most PCAC included EEG (75%) but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological exam (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities (Figure 1). Conclusions: There is wide variation in PCAC delivery among surveyed pediatric institutions. Targeting common themes such as standardization of PCAC initiation and bundle components and implementing adherence evaluation could improve PCAC.

Abstract 14159: Characteristics and Outcomes in COVID-19 Pediatric In-Hospital Cardiac Arrest Patients

Introduction: Survival of adult patients with COVID-19 who had an in-hospital cardiac arrest (IHCA) are poor. Characteristics and outcomes for pediatric IHCA patients with COVID-19 are unknown. Hypothesis: We hypothesized that pediatric COVID-19 patients would have worse survival outcomes when compared to non-COVID patients. Methods: A multicenter, multinational cohort of pediatric IHCA in the pediRES-Q collaborative were reviewed (March 1, 2020 - April 1, 2021). We characterized patients with COVID-19 compared to patients without COVID-19 and investigated whether COVID-19 was associated with survival outcomes using multivariate logistic regression with mixed effects. Results: We identified 362 pediatric IHCAs of which 14 were COVID-19 positive. For non-COVID-19 vs COVID-19 patients respectively, median [Q1; Q3] age was 1.0 [0.3; 7.1] vs. 7.1 [1.5; 14.0] years and 42% vs. 43% were female. Immediate cause of arrest was hypotension: 8% vs. 43%, respiratory decompensation: 19% vs. 21%, and hypoxia 22% vs. 36% for non-COVID-19 vs. COVID-19 patients. For non-COVID-19 vs COVID-19 patients, total CPR duration was 10 [4; 33] min vs 19 [5; 33] min (for non-return of spontaneous circulation (ROSC) cases only: 35 [20; 55] min vs 34 [24; 34] min). For non-COVID-19 vs COVID-19 patients, ROSC was 79% vs. 57%, aOR: 0.48 (95% CI: 0.24-0.98), survival to hospital discharge was 45% vs. 29%, aOR: 0.63 (95% CI: 0.25-1.57) and survival with favorable neurological outcome was 39% vs. 21%, aOR: 0.51 (95% CI: 0.16-1.65). Conclusions: In a pediatric resuscitation quality improvement collaborative, pediatric IHCA patients with COVID-19 were older when compared to non-COVID-19 patients. Median CPR duration was >30 minutes for COVID-19 non-survivors, COVID-19 patients had lower chance of ROSC when compared to non-COVID-19 patients but considerably better survival outcomes than those reported for adults.

Abstract 12921: One Hand Open Palm Technique for Infant Cardiopulmonary Resuscitation: A Randomized Crossover Study

Introduction: The American Heart Association (AHA) CPR guidelines states that effective chest compression depth, rate and recoil are essential factors for establishment of return of spontaneous circulation. A recent survey from an international pediatric resuscitation collaborative showed that healthcare providers failed to meet the metrics of the AHA guidelines, with the greatest difficulty in achieving targeted chest compression depth in infants. The recommended techniques for infant compression include two finger (TFT) or two-thumb technique (TTT). We hypothesized using the heel of one palm (open palm technique, OPT) in infants will result in improved chest compression depth with decreased provider fatigue. Methods: Each participant performed three techniques including TFT, TTT, and novel open-palm technique (OPT) with randomization for sequence of techniques for each participant. Each technique was performed for 2 minutes followed by a 5-minute rest period on an infant manikin. Data were collected through Zoll R series defibrillators on chest compression depth, rate, and fraction. At the end of the study, each participant filled out a survey for difficulty level, finger fatigue, and rescuer fatigue. Results: Thirty pediatric critical care providers participated in the study consisting of 16 nurses, 9 respiratory therapists, 3 fellows, 2 nurse practitioners. The mean chest compression depth for OPT was significantly deeper (2.61 ± 0.63 cm) in comparison to TFT (2.25 ± 0.54 cm, p= 0.0004) but not significantly deeper in comparison to TTT (2.43 ± 0.46 cm, p= 0.0820). There were no significant differences between the three techniques in chest compression rate or chest compression fraction. The finger fatigue and rescuer fatigue surveys were graded from 0-10 with 10 being the most fatigue. OPT showed significantly less finger and rescuer fatigue in comparison to TTT and TFT (p<0.05). Conclusion: This study demonstrated that OPT generated improved chest compression depth with considerably less rescuer and finger fatigue. However, chest compression depth with all three techniques failed to meet the AHA infant goal of 4 cm. Further research is needed to optimize CPR performance to achieve the targeted chest compression depth in infants.

Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest

To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.

Effect of the Use of Metronome Feedback on the Quality of Pediatric Cardiopulmonary Resuscitation

Although the use of audio feedback with devices such as metronomes during cardiopulmonary resuscitation (CPR) is a simple method for improving CPR quality, its effect on the quality of pediatric CPR has not been adequately evaluated. In this study, 64 healthcare providers performed CPR (with one- and two-handed chest compression (OHCC and THCC, respectively)) on a pediatric resuscitation manikin (Resusci Junior QCPR), with and without audio feedback using a metronome (110 beats/min). CPR was performed on the floor, with a compression-to-ventilation ratio of 30:2. For both OHCC and THCC, the rate of achievement of an adequate compression rate during CPR was significantly higher when performed with metronome feedback than that without metronome feedback (CPR with vs. without feedback: 100.0% (99.0, 100.0) vs. 94.0% (69.0, 99.0), p < 0.001, for OHCC, and 100.0% (98.5, 100.0) vs. 91.0% (34.5, 98.5), p < 0.001, for THCC). However, the rate of achievement of adequate compression depth during the CPR performed was significantly higher without metronome feedback than that with metronome feedback (CPR with vs. without feedback: 95.0% (23.5, 99.5) vs. 98.5% (77.5, 100.0), p = 0.004, for OHCC, and 99.0% (95.5, 100.0) vs. 100.0% (99.0, 100.0), p = 0.003, for THCC). Although metronome feedback during pediatric CPR could increase the rate of achievement of adequate compression rates, it could cause decreased compression depth.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study

Background The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation. Methods This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants. Results Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant’s chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants’ subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively. Conclusions The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively. Impact Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.