Elsevier

Resuscitation

Volume 188, July 2023, 109807
Resuscitation

Clinical paper
Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study

https://doi.org/10.1016/j.resuscitation.2023.109807Get rights and content

Abstract

Aims

The primary objective was to determine the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes.

Design

A retrospective cohort study was performed in two cohorts: (1) Patients with an invasive airway in place at the time of arrest to evaluate ETCO2 use, and (2) patients with an arterial line in place at the time of arrest to evaluate DBP use. The primary exposure was clinician-reported use of ETCO2 or DBP. The primary outcome was return of spontaneous circulation (ROSC). Propensity-weighted logistic regression evaluated the association between monitoring and outcomes.

Setting

Hospitals reporting to the American Heart Association’s Get With The Guidelines®– Resuscitation registry (2007–2021).

Patients

Children with index IHCA with an invasive airway or arterial line at the time of arrest.

Results

Between January 2007 and May 2021, there were 15,280 pediatric CPR events with an invasive airway or arterial line in place at the time of arrest. Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible. Clinicians reported using ETCO2 in 1335/6829 (20%) arrests and DBP in 1041/2886 (36%). Neither exposure was associated with ROSC. ETCO2 monitoring was associated with higher odds of 24-hour survival (aOR 1.17 [1.02, 1.35], p = 0.03).

Conclusions

Neither clinician-reported ETCO2 monitoring nor DBP monitoring during pIHCA were associated with ROSC. Monitoring of ETCO2 was associated with 24-hour survival.

Introduction

In-hospital cardiac arrest (IHCA) affects 15,000 American children each year1 and most occur in highly monitored care areas.2, 3 The American Heart Association (AHA) 2013 consensus statement on cardiopulmonary resuscitation (CPR) quality recommended using diastolic blood pressure (DBP) and/or end-tidal carbon dioxide (ETCO2) during CPR to monitor and/or guide CPR quality.4 These recommendations were added to the Pediatric Advanced Life Support guidelines in 2015 and remained in the guidelines with the 2020 recommendations.5, 6 Observational data show improved neurologic survival following pediatric IHCA when DBP was above age-specific DBP thresholds,7 and adult data support coronary perfusion pressure as an important determinant of return of spontaneous circulation (ROSC).8 However, data to support titrating CPR to intra-arrest hemodynamics is limited to translational studies.10, 11, 12, 13, 9, 14 With regard to ETCO2, data are conflicting regarding an ETCO2 threshold associated with survival.15, 16, 17, 18 Moreover, while animal data suggest titrating CPR to ETCO2 improves outcomes,19 human data are limited. A large registry study of adult IHCA showed an association between clinician-reported monitoring of CPR quality via either ETCO2 or DBP and improved rates of ROSC.20 To our knowledge, there are no studies investigating the association between clinician-reported physiologic monitoring during IHCA and survival outcomes in children.

In two separate cohorts, we sought the association between clinician-reported ETCO2 or DBP monitoring during pediatric in-hospital cardiac arrest (pIHCA) and survival outcomes. We hypothesized that ETCO2 and DBP monitoring during pIHCA would each be associated with higher rates of ROSC. We tested this hypothesis using a propensity weighted regression analysis of index pIHCA reported to the large, multicenter AHA Get With The Guidelines®-Resuscitation (GWTG-R) registry database. As a secondary objective, we investigated the change in use of ETCO2 and DBP monitoring by calendar year. We hypothesized that the use of both ETCO2 and DBP would increase over time.

Section snippets

Materials and Methods

Get With The Guidelines® – Resuscitation (GWTG®-R) is an AHA-sponsored prospective, multicenter database of patients undergoing in-hospital resuscitation that uses Utstein-style21 data reporting. Hospitals voluntarily participate in the registry for the primary purpose of quality improvement. All participating institutions are required to comply with local regulatory and privacy guidelines and, if required, to secure institutional review board (IRB) approval. Because data are used primarily at

Results

Between January 2007 and May 2021, 15,280 pediatric CPR events had a documented invasive airway and/or arterial line in place at the time of arrest. After serial exclusions, a total of 7490 events were eligible for inclusion (Fig. 1). Of 7159 events with an invasive airway, 6829 were eligible for analysis. Of 2978 events with an arterial line, 2886 were eligible for analysis. Clinicians reported using ETCO2 to monitor CPR quality in 1335/6829 (20%) of arrests and DBP in 1041/2886 (36%). Table 1

Discussion

In patients with an invasive airway in place at the time of arrest, clinician-reported monitoring of ETCO2 during pIHCA was not associated with the primary outcome of ROSC, nor secondary outcomes of survival to discharge or survival to discharge with a favorable neurologic status. Clinician-reported monitoring of DBP was also not associated with ROSC, nor survival to discharge or survival to discharge with a favorable neurologic status in the cohort of patients with an arterial line in place at

Conclusions

Neither clinician-reported use of ETCO2 nor DBP to monitor resuscitation quality during pIHCA was associated with ROSC. Clinician-reported ETCO2 monitoring was associated with improved ROC and 24-hour survival. Clinician-reported CPR quality monitoring using ETCO2 and DBP have significantly increased over time.

Disclosures

The scientific advisory board of the AHA provided review and approval of the manuscript, and the Executive Database Steering Committee of the AHA provided additional peer review of the manuscript before submission. All authors report no financial conflicts of interest.

Support

This study was supported by the CHOP Research Institute’s Resuscitation Science Center and the CHOP Department of Anesthesiology and Critical Care funds. Dr. Morgan’s effort was supported by the National Heart, Lung, and Blood Institute (K23HL148541).

CRediT authorship contribution statement

Martha F. Kienzle: Conceptualization, Methodology, Project administration, Writing – original draft, Writing – review & editing, Visualization. Ryan W. Morgan: Conceptualization, Methodology, Writing – review & editing. Jessica S. Alvey: Methodology, Software, Validation, Formal analysis, Writing – review & editing. Ron Reeder: Methodology, Software, Validation, Formal analysis, Writing – review & editing. Robert A. Berg: Conceptualization, Methodology, Writing – review & editing. Vinay

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Vinay Nadkarni is a member of the Editorial Board of Resuscitation.

Acknowledgements

Besides Drs. Lasa, Reeder and Sutton, members of the American Heart Association's Get With The Guidelines®-Resuscitation Pediatric Research Task Force include Anne-Marie Guerguerian MD PhD FRCPC; Elizabeth E. Foglia MD MSCE; Ericka L. Fink MD MS; Joan Roberts MD; Lillian Su MD; Linda L. Brown MD MSCE; Maya Dewan MD MPH; Melania M. Bembea MD MPH PhD; Monica Kleinman MD; Punkaj Gupta MBBS; Taylor Sawyer DO Med; Todd Sweberg MD MBA.

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