Duration of CPR and Illness Category Impact Survival and Neurologic

Outcomes for In-hospital Paediatric Cardiac Arrests

Journal Club

Kavi Aucharaz

25.09.2014

Case presentation• A 9 yr old boy admitted in the ward with fever

and possible Macrophage Activation Syndrome.

• Sudden deterioration and cardiac arrest.• CPR was performed >20 mins-unsuccessful• Was this futile? How long should we perform

CPR In-hospital cardiac arrest?• What is the relationship between duration

CPR duration and its effect on neurological outcome?

BackgroundPaediatric CPR >20mins have been considered

futile after paediatric in-hospital cardiac arrests. Concept recently been questioned, although the

effect of CPR duration on outcomes has not recently been described.

Objective - to determine the relationship between CPR duration and outcomes after paediatric in-hospital cardiac arrests.

GWTG-RThe American Heart Association’s Get With The

Guidelines–Resuscitation (GWTG-R) the only national registry of in-hospital resuscitation events.

The objectives of study were to use the GWTG-R data to evaluate. ◦ The relationship between CPR duration and intact survival to

hospital. ◦ Discharge after paediatric IHCA according to patient illness

category.

Methods • AHA GWTG-R is a prospective, multi-centre registry of

IHCA and resuscitation events using Utstein-style data reporting.

• Analysis included data from 328 US and Canadian hospitals.

• Between 1 Jan. 2000- 31Dec. 2009. • Study was approved by the Institutional Review Board-

University of Pittsburgh.

Data Collection• Index events defined as the patient’s first

cardiopulmonary arrest event during the hospitalization. • Predefined patient illness categories based on patient

characteristics at the time of cardiopulmonary arrest. • General medical patients had a primary diagnosis of

medical illness that was not cardiovascular.

Data collection• Medical cardiac patients had a primary

diagnosis of medical illness that was cardiovascular.

• General surgical patients were preoperative with a general surgical illness or postoperative after non cardiac surgery.

• Surgical cardiac patients were postoperative after cardiac surgery.

• Trauma patients had single or multiple injuries.

Inclusion and Exclusion Criteria• Included all index pulseless IHCA events

occurring in patients<18 years of age for which at least 1 min. of chest compressions was provided.

• Excluded patients in whom the event began out of the hospital or in the NICU, delivery room, or nursery.

• Also excluded patients with illness categories of new-born, obstetric, or other illnesses.

Exclusion• For patients who were documented as receiving >180

minutes of chest compressions, the CPR duration variable was winsorized at a predefined maximum of 180 minutes to reduce the effects of possibly spurious outliers.

Outcome Measures• Primary outcome measure was survival to

hospital discharge.• Secondary survival measures included return of

spontaneous circulation >20 minutes.– 24-hour survival, – Survival to discharge with favourable neurological

outcome.

• Neurological outcome was determined with the use of Paediatric Cerebral Performance Category (PCPC) scales, which were assigned after a review of medical records.

Outcome measures• Favourable neurological outcome was

prospectively defined in 2 ways: – a PCPC score of 1, 2, or 3 on hospital discharge.– or discharge PCPC no worse than on admission.

• Analysis was repeated excluding a PCPC score of 3 as a favourable neurological outcome.

Statistics • Conducted analyses using SAS 9.0 (SAS Inc,

Cary, NC) and Stata 12.1 (Stata Corp, College Station, TX).

• Chest compression duration was analyzed as both a continuous variable and a categorical variable.

• Categories of CPR duration were determined with cut points used in previous studies.

Statistics • Studied CPR duration categories of 1-15, 16-35, and >35

minutes. • χ2 or Fisher exact test for categorical variables was

used.• Wilcoxon Rank-sum test, Kruskal-Wallis test, or ANOVA

for continuous variables.

Results 3419 paediatric IHCAs in 328 hospitals that fulfilled

inclusion and exclusion criteria. 56% occurred in hospitals with ≥80 paediatric beds86% occurred in hospitals with at least 20 pediatric beds. Total = (30% In hospitals 20-80 beds, 14% less than 20

beds, 56% over 80 beds) )The mean ±SD age of the study sample was 4.9±6.0

years. Almost all events were witnessed (92.0%) and monitored

(90.5%; Table 1). Witnessed or monitored 3286 (96.1)

Results • ROSC for >20 minutes occurred in 2178 patients

(64%). • 1373(40%) were still alive at 24 hours after the

event.• 954 (27.9%)survived to hospital discharge. • 651 (19.0%) had a favourable neurological

outcome • Favourable outcome (651/954)68.2% of hospital

survivors).

Utstein diagram.

Matos R I et al. Circulation. 2013;127:442-451

Copyright © American Heart Association, Inc. All rights reserved.

Results • Respiratory insufficiency (59.1%) and hypotension

(39.9%) were the most common comorbidities. • Among medical and surgical cardiac patients,

arrhythmias were present in 29.6%

Results • 2/3 of arrests occurred in the ICU. • 14.4% in the ED.• 10.0% on the inpatient ward, • 6.2% in an operative or recovery area• Hypotension, arrhythmias, and acute respiratory

insufficiency were the most common immediate precipitating causes of the arrests.

ECMO & CPR in cardiac surgical patients

• Compared with other patients, trauma patients were more likely to be older and their arrests were more likely to occur in ED.

• Surgical cardiac patients were placed on ECMO more than any other group-- no change in survival with ECMO and CPR duration.

• There was a statistical significant survival benefit for surgical cardiac patients who received>35 mins CPR and ECMO(38.5% with ECMO and 16.7% without ECMO; P<0.0001)

Adjusted probability of outcomes at hospital discharge by cardiopulmonary resuscitation (CPR) duration stratified by patient illness category (adjusted for

initial pulseless rhythm, age category, weekend, night, extracorporeal membrane oxygenation, calcium administration, sepsis, renal insufficiency,

vasoactive infusion during arrest, event location, sodium bicarbonate administration, prior history of a cardiopulmonary arrest, prearrest apnea monitor, prearrest pulse oximeter, and patient hypotension before arrest).

• In the general medical patients the OR was 1 for survival to discharge and neurological outcome

• P- IHCA Patients <18 of age for which at least 1 min of chest compressions were provided

• Risk factors- 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical and trauma.

• O- primary outcome: Survival to hospital discharge

• Secondary outcome: ROSC>20min, 24hr survival, survival to discharge with favourable neurological outcome

• Multicentre registry of IHCA and resuscitation events using Utstein-style data reporting.

• GWTG-R centres accounts 10% of all hospitals in US These volunteer centres pay a fee(More resources) as well as greater interest in CPR –may vary from other US hospitals. However may not affect the relative proportions.

• Pre defined patient illness categories -based on patients characteristics at the time of cardiopulmonary arrest.

• There was well defined inclusion and exclusion criteria.

• Objective measures of the duration of CPR was studied in the different categories.

• Chest compressions duration was analysed as both continuous variable and categorical variable

• Statistical test were used to minimise bias and cofounding variables were looked at.

• The cohort used had all been subject to the defined categories of exposure i.e intervention

• Objective primary and secondary outcome measures were looked at.( ROSC>20min, 24 hr survival and survival to discharge with favourable neurological outcome)

• Neurological outcome-paediactric cerebral performance category scales(PCPC)—validated tool used

• Well defined inclusion and exclusion criteria.

• Same tool was used to look at in the different categories-using PCPC

• This was a prospective multi-centred registry of IHPCAs—can’t be blinded

• Who led the resuscitation in the different hospitals?

• The disease severity pre-arrest would have been helpful in analysis.

• 1551/3419(45%) of the patients were combined(Gen. Surgery, Surg.cardiac, medical cardiac)not true presentation of general paediatrics

• Event time of the day• Event day of the week• ECMO• Calcium bolus during

arrest• underlying sepsis • Vasoactive infusion• (Multivariable logistic

regression models were fit)

• Favourable neurological outcome was prospectively defined based on the PCPC score or no worse than on admission

• PCPC was used as a global measure of neurological function.

• There was lack of long term neurological follow up.

• However there are studies which have looked into the neurological outcome at 6 months and 12 mo which have shown not substantially different status from discharge.

• In first 15 mins CPR the survival rate fell linearly, decreasing by 2.1% per min of chest compressions(R2 =0.9992)

• Survival rate continues to decrease with increasing CPR

• The probability of favourable neurological outcome fell linearly in the 1st 15 mins of CPR(R2 =0.9972).

• Trauma patients had the poorest outcome after any amount of CPR

• Outcome are best with shorter duration of CPR and that many children survive after prolonged CPR(>35 mins).

• Compared to general medical patients, surgical cardiac patients had best survival (OR, 2.5; 95% CI 1.8-3.4), followed by general surgical and medical cardiac patients(P<0.0001).

• Compared with general medical patients, surgical cardiac patients had the highest odds of achieving a favourable neurological outcome(OR, 2.7; 95% CI 2.0-3.9; P<0.01)

• Trauma patients have decreased odds of favourable neurological outcome compared with gen. medical group(OR, 0.2; 95% CI, 0.1-0.4;P<0.001)

• Although a prospective observational study it was well designed.

• There were good inclusion and exclusion criteria.

• Confounding factors were taken into account.

• The results were not generalizable-newborns were excluded who were in NICU,(Gen. surgical and surgical cardiac).

• The practice in the different hospitals may have been different and this can affect the results

• Few inconsistent data in the paper and the supplemental tables

• The cohort had 45% patients with Med/surgical cardiac and general surgical patients.

• The study highlights in certain illness categories such as surgical cardiac patients have favourable probabilities of good neurological survival after longer durations of CPR.

• In our setting we will have less surgical cardiac patients.

• We may consider longer duration of CPR in cardiac medical patients .

• In multiple trauma cases it would be futile to continue prolonged CPR due to poor outcome.

• Prolonged resuscitation cannot be generalised, the pre-arrest condition and diagnosis is an important factor to be considered

• Reis AG, Nadkarni V, Perondi MB, Grisi S, Berg RA. A prospective inves-tigation into the epidemiology of in-hospital pediatric cardiopulmonary resuscitation using the international Utstein reporting style. Pediatrics. 2002;109:200–209.

• Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA; American Heart Association National Registry of CPR Investigators. Out-comes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354:2328–2339.

• Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan.Citation:Resuscitation, 04 2009, vol./is. 80/4(443-8), 0300-9572;0300-9572 (2009 Apr)

• Author(s):Wu ET,Li MJ,Huang SC,Wang CC,Liu YP,Lu FL,Ko WJ,Wang MJ,Wang JK,Wu MH

• The survival outcomes are similar to recent paediatric IHCA. Other studies have also reported favourable neurological survival 14-22%.

• Proportion of children who would presumable die without CPR survive with a favourable neurological outcome even after prolonged CPR

• Raise awareness that some categories of children eg Cardiac surgical and general surgical patients do better after prolonged CPR

• Trauma patients have the poorest outcome with any period of CPR.