Clinical paperClinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study
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.
References (41)
- et al.
Hemodynamic directed CPR improves short-term survival from asphyxia-associated cardiac arrest
Resuscitation
(2013) - et al.
Hemodynamic Directed CPR Improves Cerebral Perfusion Pressure and Brain Tissue Oxygenation
Resuscitation
(2014) - et al.
A hemodynamic-directed approach to pediatric cardiopulmonary resuscitation (HD-CPR) improves survival
Resuscitation
(2017) - et al.
Initial end-tidal CO2 partial pressure predicts outcomes of in-hospital cardiac arrest
Am J Emerg Med
(2016) - et al.
Quantitative relationship between end-tidal carbon dioxide and CPR quality during both in-hospital and out-of-hospital cardiac arrest
Resuscitation
(2015) - et al.
End-tidal Carbon Dioxide During Pediatric In-Hospital Cardiopulmonary Resuscitation
Resuscitation
(2018) - et al.
The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review
Resuscitation
(2018) - et al.
Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study
Resuscitation
(2016) Assessing the outcome of pediatric intensive care
J Pediatr
(1992)- et al.
The epidemiology and outcomes of pediatric in-hospital cardiopulmonary arrest in the United States during 1997 to 2012
Resuscitation
(2016)
Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest
Resuscitation
Correlation of end-tidal CO2 to cerebral perfusion during CPR
Ann Emerg Med
The effects of epinephrine/norepinephrine on end-tidal carbon dioxide concentration, coronary perfusion pressure and pulmonary arterial blood flow during cardiopulmonary resuscitation
Resuscitation
Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest - A report from the American Heart Association Get With The Guidelines®-Resuscitation
Resuscitation
Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States
Circ Cardiovasc Qual Outcomes
Trends in Survival after Pediatric In-Hospital Cardiac Arrest in the United States
Circulation
Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing
Crit Care Med
Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital
Circulation
Part 12: Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care
Circulation
Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Cited by (3)
Wolf Creek XVII Part 6: Physiology-Guided CPR
2024, Resuscitation PlusSensitive assessment of ETCO<inf>2</inf> on circulatory function in critical ill patient — A narrative review
2024, Trends in Anaesthesia and Critical CarePhysiologic monitoring during Pediatric Cardiac Arrest: Are we flying blind?
2023, Resuscitation