Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan

doi:10.1016/j.resuscitation.2009.01.006

Resuscitation

Volume 80, Issue 4, April 2009, Pages 443-448

https://doi.org/10.1016/j.resuscitation.2009.01.006 Get rights and content

Abstract

Purpose of the study

While the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.

Methods

Data were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).

Results

We identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p < 0.05).

Conclusions

Outcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.

Introduction

Although cardiopulmonary resuscitation (CPR) has been available for children for more than 50 years,¹ the results remain far from satisfactory. As the Utstein template is suggested as the standard for reporting the outcomes of CPR,² there are several studies of in-hospital cardiac arrests (IHCA) in children, such as national registry of cardiopulmonary resuscitation (NRCPR) in United States,3, 4 Canada,5, 6 South America,⁷ Australia,⁸ and European countries.9, 10, 11, 12 These data are lacking for Asian countries. The goal of this study was to report the outcomes of IHCA among pediatric patients in our institute and compare them to those of Western countries.

Section snippets

Hospital setting

NTUH is a university-affiliated tertiary teaching hospital, with a 120-bed pediatric department. The hospital has a 13-bed pediatric intensive care unit (PICU). According to hospital policy, there are always manpower and monitoring devices within the PICU or emergency department in the hospital so that there is no need to call for a CPR team when IHCA occurs in these locations. Otherwise, the pediatric CPR team helps manage any cardiorespiratory arrest outside the aforementioned areas, such as

Results

During the study period, 316 cardiac arrests occurred that resulted in CPR; the incidence was 0.9% out of 35,497 pediatric admissions and 5.7% out of 5514 PICU admissions, which was higher than the report from Australia (0.1 and 2.4%, respectively)⁸ and Canada (0.94% for PICU admissions),⁶ but lower than in Finland (0.7 and 7.5%)¹²and Brazil (2.14 and 19%).⁷ In this cohort, 228 patients (72.2%) ever achieved ROSC, 174 patients (55.1%) had 24-h survival, 66 patients (20.9%) survived to discharge

Discussion

We describe the outcomes of CPR for pediatric IHCA at National Taiwan University Hospital, based on Utstein template. The overall hospital survival was 20.9% and 16.1% of the patients had favorable good neurological outcomes. Of the 252 patients who received conventional CPR, 60.7% had sustained ROSC, 48.0% had 24 h survival, 19.8% survival to discharge, 17.9% survived 1 year and only 15.5% had good neurological outcomes. We also identified the risk factors that were associated with poor

Conclusions

In conclusion, about 20.9% of the children who had IHCA at National Taiwan University Hospital survived to discharge and 16.1% had good neurological outcomes at discharge. This is comparable to previous reports, but more hematologic/oncologic patients are included than previous studies. Several factors are associated with poor outcomes, including hematologic and oncologic disease, long CPR duration, and vasoactive infusions before IHCA. Besides, CPR during off-work hours resulted in inferior

Conflict of interest

There is no financial or personal relationship with other people or organizations that could inappropriately influence our work in this report.

Acknowledgments

We thank Dr. Fu-Chang Hu, National Center of Excellence for General Clinical Trial and Research, National Taiwan University Hospital and College of Public Health, National Taiwan University, for his help in the statistical computing and logistic regression analysis of the data.

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Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study
2023, Resuscitation Plus
In-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country.
This observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days.
Of 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007–0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065–0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069–0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014–0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130–0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days.
In-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.
Sodium bicarbonate administration during in-hospital pediatric cardiac arrest: A systematic review and meta-analysis
2021, Resuscitation
Citation Excerpt :
Matos et al. demonstrated that CPR duration was an independent factor associated with increased mortality.50 In our meta-analysis, several included studies also revealed a significant increase in CPR duration in the non-survival group and SB was administered more frequently to patients with prolonged cardiac arrest.11,32–37 Therefore, SB administration might be a last-ditch effort to obtain ROSC rather than a factor that caused a decreased survival rate.
Current American Heart Association Pediatric Life Support (PLS) guidelines do not recommend the routine use of sodium bicarbonate (SB) during cardiac arrest in pediatric patients. However, SB administration during pediatric resuscitation is still common in clinical practice. The objective of this study was to assess the impact of SB on mortality and neurological outcomes in pediatric patients with in-hospital cardiac arrest.
We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to January 2021. We included studies of pediatric patients that had two treatment arms (treated with SB or not treated with SB) during in-hospital cardiac arrest (IHCA). Risk of bias was assessed using the Newcastle-Ottawa Scale and the certainty of evidence was assessed using GRADE system.
We included 7 observational studies with a total of 4877 pediatric in-hospital cardiac arrest patients. Meta-analysis showed that SB administration during pediatric cardiac resuscitation was associated with a significantly decreased rate of survival to hospital discharge (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.25–0.63, p value = 0.0003). There were insufficient studies for 24-h survival and neurologic outcomes analysis. The subgroup analysis showed a significantly decreased rate of survival to hospital discharge in both the “before 2010” subgroup (OR 0.47; 95% CI 0.30–0.73; p value = 0.006) and the “after 2010” subgroup (OR 0.46; 95% CI 0.25–0.87; p value = 0.02). The certainty of evidence ranged from very low to low.
This meta-analysis of non-randomized studies supported current PLS guideline that routine administration of SB is not recommended in pediatric cardiac arrest except in special resuscitation situations.
The protocol was registered with PROSPERO on 8 August 2020 (registration number: CRD42020197837).
European Resuscitation Council Guidelines 2021: Paediatric Life Support
2021, Resuscitation
Citation Excerpt :
appendix RR 31.3).143 Since 2010, one narrative review732 and nine observational trials were published describing the association between the administration of sodium bicarbonate (or THAM) and outcomes in paediatric CA (appendix RR 31.4).14,730,733–738 Whilst these studies are likely to be confounded by the association between administration of sodium bicarbonate and longer CPR duration, none provide any evidence to change the recommendation that bicarbonate should not be given routinely in paediatric CA.
The landscape of paediatric in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit
2020, Resuscitation
To report the patient characteristics and clinical outcome of paediatric in-hospital cardiac arrest in the United Kingdom (UK) National Cardiac Arrest Audit (NCAA) database.
Analysis of all recorded paediatric cardiac arrests in the NCAA dataset over a seven-year period ending on 31 December 2018, within acute children’s hospitals (including standalone paediatric hospitals and hospitals with tertiary paediatric services) and acute general hospitals participating in NCAA. In this period 1456 patients (with 1580 events), 1 month to 16 years of age, received chest compressions and/or defibrillation and were attended by a hospital-based resuscitation team in response to an emergency call. The main outcome measure was survival to discharge.
For this cohort of paediatric in-hospital cardiac arrest patients the overall rates of sustained return of spontaneous circulation (ROSC) were 69.1% with unadjusted survival to hospital discharge of 54.2%. The presenting rhythm was shockable in 4.3% of events and non-shockable in 82.1% (remainder undetermined); rates of survival to hospital discharge associated with these rhythms were 63.9% and 51.7%. A difference in outcomes was observed between Children’s hospitals and acute general hospitals with ROSC rates of 79.1% and 55.5% respectively and survival to hospital discharge rates of 57.7% and 49.3% respectively.
These first results from the NCAA database describing the outcome of paediatric in-hospital cardiac arrest in UK hospitals will serve as a benchmark from which to assess the future impact of changes in service delivery, organisation and treatment for in-hospital cardiac arrest in young people. Outcomes for specialist paediatric centres should be studied further as higher rates of ROSC and survival to hospital discharge were observed.
Cardiopulmonary resuscitation (CPR) in children with heart disease
2018, Critical Heart Disease in Infants and Children
Over the past two decades survival from pediatric cardiac arrest has improved dramatically, particularly in the in-hospital setting, from 15% to nearly 50%. The reasons for this are multifactorial and include but are likely not limited to the use of ECPR, personalizing the care delivered to the child's age and also the child's underlying cardiac anatomy and physiology, and applying a multitude of approaches to improving the quality of care we deliver. Teams are now systematically addressing the quality of cardiopulmonary resuscitation (CPR) delivered during the event with real-time feedback with bedside devices and quality CPR coaches, postevent debriefing, and meticulously managing the post–cardiac arrest care period. Unfortunately, there is evidence of great variability between hospitals, suggesting there are still lives to be saved. In the upcoming decades we need to continue to explore physiologic targets to optimize coronary and cerebral perfusion while minimizing harm from compressions, use human factors to improve team dynamics and room ergonomics, refine approaches to post–cardiac arrest care, and improve our ability to prognosticate on outcomes. Although avoiding a cardiac arrest is always best, we now know that many lives can be saved with exquisite CPR, and we must continue to focus on optimizing outcomes for these most vulnerable of patients.
The epidemiology and outcomes of pediatric in-hospital cardiopulmonary arrest in the United States during 1997 to 2012
2016, Resuscitation
Citation Excerpt :
One study that examined national temporal trends of adult IHCA incidence demonstrated an increase in IHCA event rate from 2003 to 2007.13 Pediatric IHCA incidence rates range from 1.1/1000 to 21/1000.1–4 It is difficult to compare these results for trend analysis because of the heterogeneity among the studies.
Evaluate the trends in the incidence of in-hospital cardiopulmonary arrest (IHCA) and the associated mortality rate in children during 1997 to 2012.
Retrospective cohort study using the Kids’ Inpatient Database (KID).
Demographic and outcome data on children under 18 years of age with and without IHCA were extracted from the KID 1997 through 2012. ICD-9 procedure codes 99.60 or 99.63 were used to define IHCA. Chi-square, Chi-square for trend, and independent Student's t-test were used to analyze the data.
A total of 29,577 discharges with IHCA were identified. The overall incidence of pediatric IHCA was 0.78/1000 discharges with a mortality rate of 46%. The incidence of pediatric IHCA increased significantly from 0.57 in 1997 to 1.01 in 2012 (p < 0.05). The mortality rate after IHCA decreased significantly from 51% in 1997 to 40% in 2012 (p < 0.05). The incidence of IHCA was significantly higher for males, infants, black children, children from metropolitan regions and children from lower median household income regions (p < 0.05). The mortality rate was significantly higher for teenagers, black children, Hispanic children and children from metropolitan regions (p < 0.05).
The incidence of pediatric IHCA in the United States has increased from 1997 to 2012 while the mortality has decreased. The incidence of IHCA is higher among males, infants, black children, children from metropolitan regions and children from lower household income regions. The mortality after IHCA is higher among teenagers, black children, Hispanic children and children from metropolitan regions.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.01.006.

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Clinical paperSurvey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan☆

Abstract

Purpose of the study

Methods

Results

Conclusions

Introduction

Section snippets

Hospital setting

Results

Discussion

Conclusions

Conflict of interest

Acknowledgments

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Am J Med

Resuscitation

Resuscitation

External cardiac compression. Method, results, and complications

Pediatrics

Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital ‘Utstein style’. American Heart Association

Circulation

First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults

JAMA

Outcomes of in-hospital ventricular fibrillation in children

N Engl J Med

Clinical paper
Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan☆