Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation ...science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.
The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the ...International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
OBJECTIVES:To characterize the landscape of process of care and safety outcomes for tracheal intubation across pediatric intensive care units
BACKGROUND:Procedural process of care and safety outcomes ...of tracheal intubation across pediatric intensive care units has not been described. We hypothesize that the novel National Emergency Airway Registry for Children registry is a feasible tool to capture tracheal intubation process of care and outcomes.
DESIGN:Prospective, descriptive.
SETTING:Fifteen academic PICUs in North America.
PATIENTS:Critically ill children requiring tracheal intubation in PICUs.
INTERVENTIONS:Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubation in 15 PICUs from July 2010 to December 2011 using the National Emergency Airway Registry for Children tool with explicit site-specific compliance plans and operational definitions including adverse tracheal intubation associated events.
MEASUREMENT AND MAIN RESULTS:One thousand seven hundred fifteen tracheal intubation encounters were reported (averaging 1/3.4 days, or 1/86 bed days). Ninety-eight percent of primary tracheal intubation were successful; 86% were successful with less than or equal to two attempts. First attempt was by pediatric residents in 23%, pediatric critical care fellows in 41%, and critical care attending physicians in 13%first attempt success rate was 62%, first provider success rate was 79%. The first method was oral intubation in 1,659 (98%) and nasal in 55 (2%). Direct laryngoscopy was used in 96%. Ninety percent of tracheal intubation were with cuffed tracheal tubes. Adverse tracheal intubation associated events were reported in 20% of intubations (n = 372), with severe tracheal intubation associated events in 6% (n = 115). Esophageal intubation with immediate recognition was the most common tracheal intubation associated events (n = 167, 9%). History of difficult airway, diagnostic category, unstable hemodynamics, and resident provider as first airway provider were associated with occurrence of tracheal intubation associated events. Severe tracheal intubation associated events were associated with diagnostic category and pre-existing unstable hemodynamics. Elective tracheal intubation status was associated with fewer severe tracheal intubation associated events.
CONCLUSIONS:National Emergency Airway Registry for Children was feasible to characterize PICU tracheal intubation procedural process of care and safety outcomes. Self-reported adverse tracheal intubation associated events occurred frequently and were associated with patient, provider, and practice characteristics.
The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association ...between number of TI attempts and severe desaturation (SpO2 < 70 %) and adverse TI associated events (TIAEs).
We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80 % during TI attempt), severe desaturation (<70 %), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment).
Of 3382 TIs, 2080(65 %) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60 %), second attempt in 503/2080(24 %), and ≥3 attempts in 321/2080(15 %). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16 %, 2 attempts:36 %, ≥3 attempts:56 %, p < 0.001; adjusted OR for 2 attempts: 2.995 % CI:2.3-3.7; ≥3 attempts: 6.595 % CI: 5.0-8.5, adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12 %, 2 attempts:30 %, ≥3 attempts:44 %, p < 0.001); adjusted OR for 2 attempts: 3.195 % CI:2.4-4.0; ≥3 attempts: 5.795 % CI: 4.3-7.5 ). TIAE rates increased from 10 to 29 to 38 % with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.795 % CI:2.9-4.9 ; ≥3 attempts: 5.595 % CI: 4.1-7.4. Severe TIAE rates went from 5 to 8 to 9 % (p = 0.008); adjusted OR for 2 attempts: 1.6 95 % CI:1.1-2.4; ≥3 attempts: 1.895 % CI:1.1-2.8.
Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.
CONTEXT Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless ...electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. OBJECTIVE To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. DESIGN, SETTING, AND PATIENTS A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004. A total of 36 902 adults (≥18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. MAIN OUTCOME MEASURE Survival to hospital discharge. RESULTS The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% 236/880 vs 18% 6485/36 902; adjusted odds ratio OR, 2.29; 95% confidence interval CI, 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36 902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P<.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11 963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P<.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% 135/563 in children vs 11% 2719/24 987 in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). CONCLUSIONS In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In ...2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.
Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral ...oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first.
One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension PbtO
) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first.
With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001).
This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.
To describe the clinical manifestations and outcomes of critically ill children with coronavirus disease-19 (COVID-19) in New York City.
Retrospective observational study of children 1 month to ...21 years admitted March 14 to May 2, 2020, to 9 New York City pediatric intensive care units (PICUs) with severe acute respiratory syndrome coronavirus 2 infection.
Of 70 children admitted to PICUs, median age was 15 (IQR 9, 19) years; 61.4% male; 38.6% Hispanic; 32.9% black; and 74.3% with comorbidities. Fever (72.9%) and cough (71.4%) were the common presenting symptoms. Twelve patients (17%) met severe sepsis criteria; 14 (20%) required vasopressor support; 21 (30%) developed acute respiratory distress syndrome (ARDS); 9 (12.9%) met acute kidney injury criteria; 1 (1.4%) required renal-replacement therapy, and 2 (2.8%) had cardiac arrest. For treatment, 27 (38.6%) patients received hydroxychloroquine; 13 (18.6%) remdesivir; 23 (32.9%) corticosteroids; 3 (4.3%) tocilizumab; and 1 (1.4%) anakinra; no patient was given immunoglobulin or convalescent plasma. Forty-nine (70%) patients required respiratory support: 14 (20.0%) noninvasive mechanical ventilation, 20 (28.6%) invasive mechanical ventilation (IMV), 7 (10%) prone position, 2 (2.8%) inhaled nitric oxide, and 1 (1.4%) extracorporeal membrane oxygenation. Nine (45%) of the 20 patients requiring IMV were extubated by day 14 with median IMV duration of 218 (IQR 79, 310.4) hours. Presence of ARDS was significantly associated with duration of PICU and hospital stay, and lower probability of PICU and hospital discharge at hospital day 14 (P < .05 for all).
Critically ill children with COVID-19 predominantly are adolescents, have comorbidities, and require some form of respiratory support. The presence of ARDS is significantly associated with prolonged PICU and hospital stay.
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