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Pediatric Critical Care Medicine : a... Oct 2017In-hospital cardiac arrest occurs in 2.6-6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about... (Observational Study)
Observational Study
OBJECTIVES
In-hospital cardiac arrest occurs in 2.6-6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about cardiac arrest in pediatric cardiac ICUs; therefore, we aimed to describe cardiac arrest epidemiology in a contemporary multicenter cardiac ICU cohort.
DESIGN
Retrospective analysis within the Pediatric Cardiac Critical Care Consortium clinical registry.
SETTING
Cardiac ICUs within 23 North American hospitals.
PATIENTS
All cardiac medical and surgical patients admitted from August 2014 to July 2016.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
There were 15,908 cardiac ICU encounters (6,498 medical, 9,410 surgical). 3.1% had cardiac arrest; rate was 4.8 cardiac arrest per 1,000 cardiac ICU days. Medical encounters had 50% higher rate of cardiac arrest compared with surgical encounters. Observed (unadjusted) cardiac ICU cardiac arrest prevalence varied from 1% to 5.5% among the 23 centers; cardiac arrest per 1,000 cardiac ICU days varied from 1.1 to 10.4. Over half cardiac arrest occur within 48 hours of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category 4, 5 had strongest association with surgical encounter cardiac arrest. In medical encounters, independent cardiac arrest risk factors were acute heart failure, prematurity, lactic acidosis greater than 3 mmol/dL, and invasive ventilation 1 hour after admission. Median cardiopulmonary resuscitation duration was 10 minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal cardiopulmonary resuscitation in 27.2%. Unadjusted survival was 53.2% in encounters with cardiac arrest versus 98.2% without. Medical encounters had lower survival after cardiac arrest (37.7%) versus surgical encounters (62.5%); Norwood patients had less than half the survival after cardiac arrest (35.6%) compared with all others. Unadjusted survival after cardiac arrest varied greatly among 23 centers.
CONCLUSIONS
We provide contemporary epidemiologic and outcome data for cardiac arrest occurring in the cardiac ICU from a multicenter clinical registry. As detailed above, we highlight high-risk patient cohorts and periods of time that may serve as targets for research and quality improvement initiatives aimed at cardiac arrest prevention.
Topics: Adolescent; Adult; Cardiopulmonary Resuscitation; Child; Child, Preschool; Female; Heart Arrest; Heart Defects, Congenital; Humans; Infant; Infant, Newborn; Intensive Care Units, Pediatric; Logistic Models; Male; North America; Odds Ratio; Prevalence; Registries; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; Young Adult
PubMed: 28737598
DOI: 10.1097/PCC.0000000000001273 -
Folia Neuropathologica 2017. (Review)
Review
.
Topics: Alzheimer Disease; Heart Arrest; Humans
PubMed: 29363901
DOI: 10.5114/fn.2017.72384 -
Pediatric Critical Care Medicine : a... Apr 2020In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not...
OBJECTIVES
In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes.
DESIGN
Retrospective single-center cohort study.
SETTING
PICU of a quaternary care, academic children's hospital.
PATIENTS
Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85).
CONCLUSIONS
Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.
Topics: Adult; Cardiopulmonary Resuscitation; Child; Cohort Studies; Heart Arrest; Humans; Hypertension, Pulmonary; Prevalence; Retrospective Studies; Treatment Outcome
PubMed: 31688674
DOI: 10.1097/PCC.0000000000002187 -
Current Opinion in Critical Care Jun 2018To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and... (Comparative Study)
Comparative Study Review
PURPOSE OF REVIEW
To review the epidemiology, peri-arrest management, and research priorities related to in-hospital cardiac arrest (IHCA) and explore key distinctions between IHCA and out-of-hospital cardiac arrest (OHCA) as they pertain to the clinician and resuscitation scientist.
RECENT FINDINGS
IHCA is a common and highly morbid event amongst hospitalized patients in the United States. As compared with patients who experience an OHCA, patients who experience an IHCA tend to have more medical comorbidities, have a witnessed arrest, and be attended to by professional first responders. Further, providers resuscitating patients from IHCA commonly have access to tools and information not readily available to the OHCA responders. Despite these differences, society guidelines for the peri-arrest management of patients with IHCA are often based on data extrapolated from the OHCA population. To advance the care of patients with IHCA, clinicians and investigators should recognize the many important distinctions between OHCA and IHCA.
SUMMARY
IHCA is a unique disease entity with an epidemiology and natural history that are distinct from OHCA. In both research and clinical practice, physicians should recognize these distinctions so as to advance the care of IHCA victims.
Topics: Adult; Aged; Aged, 80 and over; Cardiopulmonary Resuscitation; Emergency Medical Services; Female; Heart Arrest; Humans; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Practice Guidelines as Topic; Survival Rate; Treatment Outcome; United States
PubMed: 29688939
DOI: 10.1097/MCC.0000000000000505 -
Anesthesiology Sep 2021
Review
Topics: Heart Arrest; Humans; Point-of-Care Systems; Ultrasonography, Interventional
PubMed: 33979442
DOI: 10.1097/ALN.0000000000003811 -
European Journal of Trauma and... Oct 2023Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and...
Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.
INTRODUCTION
Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.
MATERIAL AND METHODS
The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.
RESULTS
This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.
CONCLUSIONS
Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
Topics: Humans; Anesthesiology; Critical Care; Heart Arrest; Resuscitation; Thoracotomy
PubMed: 37430174
DOI: 10.1007/s00068-023-02271-3 -
Minerva Anestesiologica Mar 2021Postcardiac arrest myocardial dysfunction (PCAMD) is a frequent complication faced during post-resuscitation care that adversely impacts survival and neurological...
Postcardiac arrest myocardial dysfunction (PCAMD) is a frequent complication faced during post-resuscitation care that adversely impacts survival and neurological outcome. Both mechanical and electrical factors contribute to the occurrence of PCAMD. Prearrest ventricular function, the cause of cardiac arrest, global ischemia, resuscitation factors, ischemia/reperfusion injury and post-resuscitation treatments contribute to the severity of PCMAD. The pathophysiology of PCAMD is complex and include myocytes energy failure, impaired contractility, cardiac edema, mitochondrial damage, activation of inflammatory pathways and the coagulation cascade, persistent ischemic injury and myocardial stiffness. Hypotension and low cardiac output with vasopressor/inotropes need are frequent after resuscitation. However, clinical, hemodynamic and laboratory signs of shock are frequently altered by cardiac arrest pathophysiology and post-resuscitation treatment, potentially being misleading and not fully reflecting the severity of postcardiac arrest syndrome. Even if validated criteria are lacking, an extensive hemodynamic evaluation is useful to define a "benign" and a "malign" form of myocardial dysfunction and circulatory shock, potentially having treatment and prognostic implications. Cardiac output is frequently decreased after cardiac arrest, particularly in patients treated with target temperature management (TTM); however, it is not independently associated with outcome. Sinus bradycardia during TTM seems independently associated with survival and good neurological outcome, representing a promising prognostic indicator. Higher mean arterial pressure (MAP) seems to be associated with improved survival and cerebral function after cardiac arrest; however, two recent randomized clinical trials failed to replicate these results. Recommendations on hemodynamic optimization are relatively poor and are largely based on general principle of intensive care medicine.
Topics: Arterial Pressure; Cardiac Output; Cardiopulmonary Resuscitation; Heart Arrest; Hemodynamics; Humans
PubMed: 32959631
DOI: 10.23736/S0375-9393.20.14574-7 -
Minerva Anestesiologica Jan 2015The mortality of postcardiac arrest patients has gradually reduced in years but it still is as high as 50%, despite advancements in the diagnostic and therapeutic... (Review)
Review
The mortality of postcardiac arrest patients has gradually reduced in years but it still is as high as 50%, despite advancements in the diagnostic and therapeutic approaches, i.e. revascularization and therapeutic moderate hypothermia. However, recent evidence suggests that other therapeutic interventions aimed to minimize progressive deterioration of the brain and other organs function might be helpful to reduce in-hospital mortality and improve neurologic outcome as well as quality of life after cardiac arrest. In this article, we discuss the role of ventilator management on the prognosis after cardiac arrest. We performed a meta-analysis showing that in adult patients not only hypoxia but also hyperoxia was associated with higher in-hospital mortality, while hypercapnia and hypocapnia worse neurologic outcome. In pediatric patients, hypoxia and hyperoxia were not associated with higher in-hospital mortality, while hypocapnia and hypercabia with higher in-hospital mortality worse neurologic outcome. We propose a general bundle for ventilator treatment after cardiac arrest, including: 1) therapeutic hypothermia for 12-24 hours; 2) mean arterial pressure ≥65-75 mmHg; 3) PaO2 between 60-200 mmHg and PCO2 between 30 and 50 mmHg; 4) protective MV with tidal volume of 6-8 mL/kg and positive end expiratory pressure of between 5-10 cmH2O; 5) monitoring of respiratory mechanics, extravascular lung water, hemodynamics, non-invasive transcranial Doppler and intracranial pressure monitoring; and 6) others supportive care, i.e. blood sugar and seizures control.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Humans; Respiration, Artificial; Respiratory Mechanics
PubMed: 24642487
DOI: No ID Found -
Acta Anaesthesiologica Scandinavica Jan 2023
Topics: Humans; COVID-19; Cardiopulmonary Resuscitation; Heart Arrest; Out-of-Hospital Cardiac Arrest; Emergency Medical Services
PubMed: 36151604
DOI: 10.1111/aas.14151 -
Resuscitation Sep 2018Cardiac arrest etiology is often assigned according to the Utstein template, which differentiates medical (formerly "presumed cardiac") from other causes. These...
INTRODUCTION
Cardiac arrest etiology is often assigned according to the Utstein template, which differentiates medical (formerly "presumed cardiac") from other causes. These categories are poorly defined, contain within them many clinically distinct etiologies, and are rarely based on diagnostic testing. Optimal clinical care and research require more rigorous characterization of arrest etiology.
METHODS
We developed a novel system to classify arrest etiology using a structured chart review of consecutive patients treated at a single center after in- or out-of-hospital cardiac arrest over four years. Two reviewers independently reviewed a random subset of 20% of cases to calculate inter-rater reliability. We used X and Kruskal-Wallis tests to compare baseline clinical characteristics and outcomes across etiologies.
RESULTS
We identified 14 principal arrest etiologies, and developed objective diagnostic criteria for each. Inter-rater reliability was high (kappa = 0.80). Median age of 986 included patients was 60 years, 43% were female and 71% arrested out-of-hospital. The most common etiology was respiratory failure (148 (15%)). A minority (255 (26%)) arrested due to cardiac causes. Only nine (1%) underwent a diagnostic workup that was unrevealing of etiology. Rates of awakening and survival to hospital discharge both differed across arrest etiologies, with survival ranging from 6% to 60% (both P < 0.001), and rates of favorable outcome ranging from 0% to 40% (P < 0.001). Timing and mechanism of death (e.g. multisystem organ failure or brain death) also differed significantly across etiologies.
CONCLUSIONS
Arrest etiology was identifiable in the majority cases via systematic chart review. "Cardiac" etiologies may be less common than previously thought. Substantial clinical heterogeneity exists across etiologies, suggesting previous classification systems may be insufficient.
Topics: Cardiopulmonary Resuscitation; Cause of Death; Classification; Diagnostic Screening Programs; Female; Heart Arrest; Heart Diseases; Humans; Male; Middle Aged; Patient Discharge; Patient Selection; Random Allocation; Reproducibility of Results; Respiratory Insufficiency; United States
PubMed: 29940296
DOI: 10.1016/j.resuscitation.2018.06.024