Excellent Outcome of Cardiopulmonary Resuscitation Performed in PICUs—Can We All Get There?* Gad Bar-Joseph, MD Pediatric Intensive Care Rambam Medical Center; and Bruce Rappaport Faculty of Medicine Technion Israel Institute of Technology Haifa, Israel
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n recent years, we encounter a flurry of studies analyzing the outcome of pediatric cardiac arrest and cardiopulmonary resuscitation (CPR). These studies related to both out-of-hospital arrests (OHCAs) and in-hospital arrests, and many of them have originated from the American Heart Association’s National Registry of Cardiopulmonary Resuscitation, now called “Get With the Guidelines–Resuscitation.” The article by Gupta et al (1) in this issue of Pediatric Critical Care Medicine analyzes an even more selective segment—cardiac arrests occurring in three PICUs in a single, tertiary care, academic children’s hospital. All of these studies are observational uncontrolled analyses—some of them of carefully recorded databases. As such, they may detect associations but do not allow drawing any conclusions regarding cause and effect. This basic fact should be kept in mind when interpreting their results. These studies highlight again the fact that outcome of in-hospital arrests is far more favorable than the outcome of OHCAs, despite the far less favorable prearrest and baseline health characteristics of the in-hospital patient population: The patients who were included in the study by Gupta et al (1) had been extremely sick—judging by their basic medical or surgical conditions and by their preevent characteristics, as demonstrated in Tables 2 and 3 in (1). Yet, these patients were “lucky enough” to be taken care of, experience cardiac arrest, and undergo CPR in three PICUs in a top-notch academic children’s hospital. They were well monitored, and “downtimes” were extremely short—basically zero minutes between code called and initiation of chest compressions and first medication; CPR was directed by fellow or faculty experts and performed by experienced, large teams in a well-equipped ICU with practically no resource limitations—including the availability of *See also p. e128. Key Words: cardiac arrest; cardiopulmonary resuscitation; children; neonatal intensive care unit; pediatric; pediatric intensive care unit The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000083
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extracorporeal membrane oxygenation CPR (ECPR). This very favorable clinical setup is therefore responsible for the remarkable overall outcome: 76% of 411 patients achieved return of spontaneous circulation, 47% survived to hospital discharge, and 39% had a good neurological status at discharge. Arrest duration was longest in the cardiovascular ICU (CVICU), with 50% of arrests lasting longer than 30 minutes. Yet, CVICU patients had higher rates of survival to hospital discharge and good neurological outcome when compared with the neonatal ICU (NICU) patients and the PICU patients. The more prevalent ECPR in the CVICU cannot fully account for these superior results. Patients in the CVICU had overall increased use of epinephrine, calcium, and sodium bicarbonate boluses during CPR, and higher proportion of nonsurvivors in the CVICU received these medications when compared with the nonsurvivors in the PICU or NICU. As justly commented by the authors, previous studies demonstrated an association between greater than or equal to 2 code-doses of epinephrine, calcium, or sodium bicarbonate, longer duration of cardiac arrests, and unfavorable CPR outcomes (2–6). The increased use of these medications was, in all probability, an “epiphenomenon” of prolonged arrest and CPR efforts and not the cause of unfavorable outcome. Yet again, the current study demonstrated that despite the more prolonged arrests and higher usage of medications, CVICU outcome was better than that of the NICU and PICU. The issue of sodium bicarbonate usage in CPR deserves a specific comment: 52% of all patients and 75% of the CVICU patients received sodium bicarbonate—obviously, a very high usage rate by the “experts.” Similarly, very high bicarbonate usage rates have been reported in recent years in pediatric in-hospital (5) and PICU (7) CPRs. This should be viewed as a rather unexpected and surprising finding in light of the poor “public relations” and basically negative recommendations bicarbonate is receiving in the past 2 decades, led in recent years by the Acute Cardiac Life Support (8) and Pediatric Advanced Life Support (9) Guidelines—guidance that have resulted in very low bicarbonate usage rates by less experienced providers in out-of-hospital CPRs (10). The current study, however, found no association between bicarbonate use and unfavorable outcome. In fact, in the unadjusted analysis, survival rate in patients receiving sodium bicarbonate was significantly higher in the CVICU (61%) when compared with the NICU (10%) and PICU (37%). The multivariable analysis did not demonstrate any association of bicarbonate with mortality. What should be the “take-home” practical message of this study? One, as shown in this study and in several others (7, 11), CPR—if performed under “optimal” circumstances as March 2014 • Volume 15 • Number 3
Editorials
in this study—is basically a very effective medical procedure. The excellent results presented in this study possibly represent a “glass ceiling” for the potential of achieving favorable outcome of CPR. Yet, the paramedic in the field should not be discouraged by the relatively low survival and unfavorable neurological outcome he/she might achieve (12, 13). He/she is simply playing in a completely different, far less favorable, playground. Second, CPR providers should not be too hesitant with pharmacologic interventions such as sodium bicarbonate and possibly repeated epinephrine: The practice in highly qualified pediatric hospitals, based on clinical considerations and vast experience, seems to disagree with the “official” guidelines. No appropriate controlled clinical trial regarding the benefit of sodium bicarbonate in cardiac arrest and CPR was ever performed, but the vast clinical experience certainly does not support the notion that it might be harmful.
REFERENCES
1. Gupta P, Yan K, Chow V, et al: Variability of Characteristics and Outcomes Following Cardiopulmonary Resuscitation Events in Diverse ICU Settings in a Single, Tertiary Care Children’s Hospital. Pediatr Crit Care Med 2014; 15:e128–e141 2. Suominen P, Olkkola KT, Voipio V, et al: Utstein style reporting of in-hospital paediatric cardiopulmonary resuscitation. Resuscitation 2000; 45:17–25 3. Young KD, Gausche-Hill M, McClung CD, et al: A prospective, population-based study of the epidemiology and outcome of outof-hospital pediatric cardiopulmonary arrest. Pediatrics 2004; 114:157–164 4. López-Herce J, García C, Domínguez P, et al; Spanish Study Group of Cardiopulmonary Arrest in Children: Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation 2004; 63:311–320
Pediatric Critical Care Medicine
5. Srinivasan V, Morris MC, Helfaer MA, et al; American Heart Association National Registry of CPR Investigators: Calcium use during in-hospital pediatric cardiopulmonary resuscitation: A report from the National Registry of Cardiopulmonary Resuscitation. Pediatrics 2008; 121:e1144–e1151 6. Wu ET, Li MJ, Huang SC, et al: Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation 2009; 80:443–448 7. Meaney PA, Nadkarni VM, Cook EF, et al; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators: Higher survival rates among younger patients after pediatric intensive care unit cardiac arrests. Pediatrics 2006; 118:2424–2433 8. Morrison LJ, Deakin CD, Morley PT, et al; Advanced Life Support Chapter Collaborators: Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S345–S421 9. Kleinman ME, de Caen AR, Chameides L, et al; Pediatric Basic and Advanced Life Support Chapter Collaborators: Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466–S515 10. Stiell IG, Wells GA, Field B, et al; Ontario Prehospital Advanced Life Support Study Group: Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004; 351:647–656 11. Moler FW, Meert K, Donaldson AE, et al; Pediatric Emergency Care Applied Research Network: In-hospital versus out-of-hospital pediatric cardiac arrest: A multicenter cohort study. Crit Care Med 2009; 37:2259–2267 12. Atkins DL, Everson-Stewart S, Sears GK, et al: Epidemiology and outcomes from out-of-hospital cardiac arrest in children: The Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009; 119:1484–1491 13. Michiels EA, Dumas F, Quan L, et al: Long-term outcomes following pediatric out-of-hospital cardiac arrest. Pediatr Crit Care Med 2013; 14:755–760
www.pccmjournal.org
283
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n recent years, we encounter a flurry of studies analyzing the outcome of pediatric cardiac arrest and cardiopulmonary resuscitation (CPR). These studies related to both out-of-hospital arrests (OHCAs) and in-hospital arrests, and many of them have originated from the American Heart Association’s National Registry of Cardiopulmonary Resuscitation, now called “Get With the Guidelines–Resuscitation.” The article by Gupta et al (1) in this issue of Pediatric Critical Care Medicine analyzes an even more selective segment—cardiac arrests occurring in three PICUs in a single, tertiary care, academic children’s hospital. All of these studies are observational uncontrolled analyses—some of them of carefully recorded databases. As such, they may detect associations but do not allow drawing any conclusions regarding cause and effect. This basic fact should be kept in mind when interpreting their results. These studies highlight again the fact that outcome of in-hospital arrests is far more favorable than the outcome of OHCAs, despite the far less favorable prearrest and baseline health characteristics of the in-hospital patient population: The patients who were included in the study by Gupta et al (1) had been extremely sick—judging by their basic medical or surgical conditions and by their preevent characteristics, as demonstrated in Tables 2 and 3 in (1). Yet, these patients were “lucky enough” to be taken care of, experience cardiac arrest, and undergo CPR in three PICUs in a top-notch academic children’s hospital. They were well monitored, and “downtimes” were extremely short—basically zero minutes between code called and initiation of chest compressions and first medication; CPR was directed by fellow or faculty experts and performed by experienced, large teams in a well-equipped ICU with practically no resource limitations—including the availability of *See also p. e128. Key Words: cardiac arrest; cardiopulmonary resuscitation; children; neonatal intensive care unit; pediatric; pediatric intensive care unit The author has disclosed that he does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000083
282
www.pccmjournal.org
extracorporeal membrane oxygenation CPR (ECPR). This very favorable clinical setup is therefore responsible for the remarkable overall outcome: 76% of 411 patients achieved return of spontaneous circulation, 47% survived to hospital discharge, and 39% had a good neurological status at discharge. Arrest duration was longest in the cardiovascular ICU (CVICU), with 50% of arrests lasting longer than 30 minutes. Yet, CVICU patients had higher rates of survival to hospital discharge and good neurological outcome when compared with the neonatal ICU (NICU) patients and the PICU patients. The more prevalent ECPR in the CVICU cannot fully account for these superior results. Patients in the CVICU had overall increased use of epinephrine, calcium, and sodium bicarbonate boluses during CPR, and higher proportion of nonsurvivors in the CVICU received these medications when compared with the nonsurvivors in the PICU or NICU. As justly commented by the authors, previous studies demonstrated an association between greater than or equal to 2 code-doses of epinephrine, calcium, or sodium bicarbonate, longer duration of cardiac arrests, and unfavorable CPR outcomes (2–6). The increased use of these medications was, in all probability, an “epiphenomenon” of prolonged arrest and CPR efforts and not the cause of unfavorable outcome. Yet again, the current study demonstrated that despite the more prolonged arrests and higher usage of medications, CVICU outcome was better than that of the NICU and PICU. The issue of sodium bicarbonate usage in CPR deserves a specific comment: 52% of all patients and 75% of the CVICU patients received sodium bicarbonate—obviously, a very high usage rate by the “experts.” Similarly, very high bicarbonate usage rates have been reported in recent years in pediatric in-hospital (5) and PICU (7) CPRs. This should be viewed as a rather unexpected and surprising finding in light of the poor “public relations” and basically negative recommendations bicarbonate is receiving in the past 2 decades, led in recent years by the Acute Cardiac Life Support (8) and Pediatric Advanced Life Support (9) Guidelines—guidance that have resulted in very low bicarbonate usage rates by less experienced providers in out-of-hospital CPRs (10). The current study, however, found no association between bicarbonate use and unfavorable outcome. In fact, in the unadjusted analysis, survival rate in patients receiving sodium bicarbonate was significantly higher in the CVICU (61%) when compared with the NICU (10%) and PICU (37%). The multivariable analysis did not demonstrate any association of bicarbonate with mortality. What should be the “take-home” practical message of this study? One, as shown in this study and in several others (7, 11), CPR—if performed under “optimal” circumstances as March 2014 • Volume 15 • Number 3
Editorials
in this study—is basically a very effective medical procedure. The excellent results presented in this study possibly represent a “glass ceiling” for the potential of achieving favorable outcome of CPR. Yet, the paramedic in the field should not be discouraged by the relatively low survival and unfavorable neurological outcome he/she might achieve (12, 13). He/she is simply playing in a completely different, far less favorable, playground. Second, CPR providers should not be too hesitant with pharmacologic interventions such as sodium bicarbonate and possibly repeated epinephrine: The practice in highly qualified pediatric hospitals, based on clinical considerations and vast experience, seems to disagree with the “official” guidelines. No appropriate controlled clinical trial regarding the benefit of sodium bicarbonate in cardiac arrest and CPR was ever performed, but the vast clinical experience certainly does not support the notion that it might be harmful.
REFERENCES
1. Gupta P, Yan K, Chow V, et al: Variability of Characteristics and Outcomes Following Cardiopulmonary Resuscitation Events in Diverse ICU Settings in a Single, Tertiary Care Children’s Hospital. Pediatr Crit Care Med 2014; 15:e128–e141 2. Suominen P, Olkkola KT, Voipio V, et al: Utstein style reporting of in-hospital paediatric cardiopulmonary resuscitation. Resuscitation 2000; 45:17–25 3. Young KD, Gausche-Hill M, McClung CD, et al: A prospective, population-based study of the epidemiology and outcome of outof-hospital pediatric cardiopulmonary arrest. Pediatrics 2004; 114:157–164 4. López-Herce J, García C, Domínguez P, et al; Spanish Study Group of Cardiopulmonary Arrest in Children: Characteristics and outcome of cardiorespiratory arrest in children. Resuscitation 2004; 63:311–320
Pediatric Critical Care Medicine
5. Srinivasan V, Morris MC, Helfaer MA, et al; American Heart Association National Registry of CPR Investigators: Calcium use during in-hospital pediatric cardiopulmonary resuscitation: A report from the National Registry of Cardiopulmonary Resuscitation. Pediatrics 2008; 121:e1144–e1151 6. Wu ET, Li MJ, Huang SC, et al: Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation 2009; 80:443–448 7. Meaney PA, Nadkarni VM, Cook EF, et al; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators: Higher survival rates among younger patients after pediatric intensive care unit cardiac arrests. Pediatrics 2006; 118:2424–2433 8. Morrison LJ, Deakin CD, Morley PT, et al; Advanced Life Support Chapter Collaborators: Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S345–S421 9. Kleinman ME, de Caen AR, Chameides L, et al; Pediatric Basic and Advanced Life Support Chapter Collaborators: Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S466–S515 10. Stiell IG, Wells GA, Field B, et al; Ontario Prehospital Advanced Life Support Study Group: Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med 2004; 351:647–656 11. Moler FW, Meert K, Donaldson AE, et al; Pediatric Emergency Care Applied Research Network: In-hospital versus out-of-hospital pediatric cardiac arrest: A multicenter cohort study. Crit Care Med 2009; 37:2259–2267 12. Atkins DL, Everson-Stewart S, Sears GK, et al: Epidemiology and outcomes from out-of-hospital cardiac arrest in children: The Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009; 119:1484–1491 13. Michiels EA, Dumas F, Quan L, et al: Long-term outcomes following pediatric out-of-hospital cardiac arrest. Pediatr Crit Care Med 2013; 14:755–760
www.pccmjournal.org
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