Cardiac arrest in the paediatric intensive care unit: defining the problem and developing solutions

Abstract

Thousands of children experience a cardiac arrest event in the hospital each year, with more than half of these patients not surviving to hospital discharge. Cardiopulmonary resuscitation (CPR) depth, rate, velocity and percentage of high-quality chest compressions are modifiable factors associated with improved survival. Therefore, we created a novel and standardised process to track and analyse cardiac arrests in the Duke paediatric intensive care unit (PICU). Our aim was to identify areas for improved American Heart Association (AHA) compliance and implement education and communication-based initiatives to enhance early recognition of at-risk patients leading to improved outcomes. From January 2017 to December 2018, all cardiac arrests in our PICU were tracked, reviewed and presented at monthly morbidity and mortality conference. We used the data to track compliance with AHA guidelines and identify opportunities for improvement. Through these efforts, we established a multidisciplinary cardiac arrest education and review programme. Over the 2-year period, we tracked 45 cardiac arrests, which comprised 2% of all PICU admissions. In 2017, during the first year of development, 16 of 22 arrests (73%) were not reported to code committee members in time for complete review. Of the six cardiac arrests with complete reviews, only 17% followed AHA guidelines. In 2018, all 23 arrest events were communicated and 76% of resuscitations were found to be compliant with AHA guidelines. Survival of patients to discharge was 47% in 2017 and increased to 63% in 2018 with similar percentage of PICU admissions having a cardiac arrest between the 2 years. The primary aim of this project was to establish a multidisciplinary comprehensive cardiac arrest review process. This programme allowed for comprehensive analysis of individual events, promoted quality improvement initiatives and improved consistent delivery of high-quality CPR.

Epidemiology of Cardiopulmonary Arrest and Outcome of Resuscitation in PICU Across China: A Prospective Multicenter Cohort Study

“…In addition, compared with Zeng's report, the current rate of ROSC was slightly lower, while the rate of survival in 24 h post-CPR and survival to discharge were apparently higher (47.3 and 37.4% vs. 35.06 and 28.2%, respectively), implying that the subsequent therapy contributed to the improvement of prognosis. In recently published international reports, the ROSC ratio varied widely from 64.5 to 78% ( 2 , 3 , 11 ), and the survival to discharge rate ranged from 45 to 63% ( 1 , 4 , 7 ), which were better than the results in this study. Thus, more studies on repeated high-quality CPR training, primary disease therapy, and effective advanced life support should be performed to narrow the gap.…”

“…This study is the only multicenter survey of CPA and CPR in PICU based on the Utstein style across China in the past 10 years. Reports in the recent 5 years have declared that the incidence of CPA in critically ill children in the hospital has decreased from 2 to 6% ( 8 , 9 ) to 2.2–5.5% ( 1 , 3 , 4 , 7 , 10 ). In this study, the incidence of CPA in PICU was 3.2%, similar to that observed in the previous studies ( 7 , 11 ) but was lower than the 5.5% in Zeng's report ( 9 ), another multicenter survey in Beijing in 2013.…”

“…Reports in the recent 5 years have declared that the incidence of CPA in critically ill children in the hospital has decreased from 2 to 6% ( 8 , 9 ) to 2.2–5.5% ( 1 , 3 , 4 , 7 , 10 ). In this study, the incidence of CPA in PICU was 3.2%, similar to that observed in the previous studies ( 7 , 11 ) but was lower than the 5.5% in Zeng's report ( 9 ), another multicenter survey in Beijing in 2013. However, a possible decrease in the incidence of CPA in the PICU was difficult to determine because of the evident difference in the study population between the two studies.…”

Cardiac Children Hospital Early Warning ScoreVersus the Inadequate Oxygen Delivery Index for the Detection of Early Warning Signs of Deterioration

“…C-CHEWS is normally done every 4 hours per McLellan et al ( 5 ), but since PCICU is a high dependency unit, we collected C-CHEWS and IDO 2 scores every 2 hours, starting immediately after extubating and continued till discharge/transfer from PCICU. If a patient’s C-CHEWS scores were in yellow ( 3 , 4 ) or red (≥5), the frequency of C-CHEWS and IDO 2 was increased to once every hour. Adverse events were defined as a need for reintubation, cardiopulmonary resuscitation (CPR), or death.…”

“…Furthermore, CA is associated with significant morbidity due to ischemic brain injury and poor neurological outcomes ( 3 ). Studies have shown an increase in survival to discharge rate by up to 16% by implementing educational and community-based initiatives to improve recognition of early signs of CA ( 4 ). This lays special emphasis on the importance of early recognition of such adverse events to improve morbidity and mortality rates associated with CA.…”