Outcomes After In-Hospital Cardiac Arrest in Children With Cardiac Disease

Abstract

Background— Small studies suggest that children experiencing a cardiac arrest after undergoing cardiac surgery have better outcomes than other groups of patients, but the survival outcomes and periarrest variables of cardiac and noncardiac pediatric patients have not been compared. Methods and Results— All cardiac arrests in patients <18 years of age were identified from Get With the Guidelines–Resuscitation from 2000 to 2008. Cardiac arrests occurring in the neonatal intensive care unit were excluded. Of 3323 index cardiac arrests, 19% occurred in surgical-cardiac, 17% in medical-cardiac, and 64% in noncardiac (trauma, surgical-noncardiac, and medical-noncardiac) patients. Survival to hospital discharge was significantly higher in the surgical-cardiac group (37%) compared with the medical-cardiac group (28%; adjusted odds ratio, 1.8; 95% confidence interval, 1.3–2.5) and the noncardiac group (23%; adjusted odds ratio, 1.8; 95% confidence interval, 1.4–2.4). Those in the cardiac groups were younger and less likely to have preexisting noncardiac organ dysfunction, but were more likely to have ventricular arrhythmias as their first pulseless rhythm, to be monitored and hospitalized in the intensive care unit at the time of cardiac arrest, and to have extracorporeal cardiopulmonary resuscitation compared with those in the noncardiac group. There was no survival advantage for patients in the medical-cardiac group compared with those in the noncardiac group when adjusted for periarrest variables. Conclusion— Children with surgical-cardiac disease have significantly better survival to hospital discharge after an in-hospital cardiac arrest compared with children with medical-cardiac disease and noncardiac disease.

Multidisciplinary Review of Code Events in a Heart Center

“…16 Review of cardiac surgical data at our institution demonstrates that our overall incidence of cardiopulmonary arrests is similar to the incidences reported in other published data series 3,4,17 at 3% to 6% per year. The Get With The Guidelines-Resuscitation database www.ajcconline.org report 13 from 2011 reported a subgroup of cardiac surgical patients with a survival to discharge of 37%, which was similar to our experience in 2010 and 2011. Over time, our survival rate after cardiopulmonary arrest has improved each year with survival to discharge reaching 55% in 2012 and 81% in 2013, exceeding reported survival rates of 37% to 48% in this specific population.…”

“…Over time, our survival rate after cardiopulmonary arrest has improved each year with survival to discharge reaching 55% in 2012 and 81% in 2013, exceeding reported survival rates of 37% to 48% in this specific population. 13,17 This survival rate would suggest that our heart center has lowered our failure-to-rescue rate specifically related to cardiopulmonary arrests in the cardiac surgical patients. Additionally, we have noticed a downward trend, which is not yet significant, in the percentage of cardiopulmonary arrests deemed "potentially preventable."…”

“…After approval from the institutional review board, we retrospectively reviewed deidentified quality improvement findings from 47 cardiopulmonary arrests occurring between September 2010 and December 2013. All reviews were summarized by 3 individuals, with findings from reviews categorized into different domains including the type of cardiopulmonary arrest (cardiac vs respiratory), the cause of cardiopulmonary arrest (airway compromise, acute respiratory insufficiency, arrhythmia, hypotension/hypoperfusion, or metabolic/electrolyte abnormality as previously defined 13 ), preventable aspect of the cardiopulmonary arrest, communication issues, care-related issues, equipment issues, or environment/ culture/policy issues. Outcomes from the code review were grouped into categories consisting of new education, equipment change, staffing change, or policy change.…”

Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support

“…We also identified low-quality evidence (downgraded for indirectness, inconsistency, and residual confounding) from a single pediatric study of IHCA 76 that showed benefit to ECPR when compared with CPR without the use of ECMO (OR, 2.5; 95% CI, 1.3-4.5; P50.007 in surgical cardiac diagnoses; OR, 3.8; 95% CI, 1.4-5.8; P50.011 in medical cardiac diagnoses).…”

What is new in the 2015 American Heart Association guidelines, what is recycled from 2010, and what is relevant for emergency medicine in Canada

“…25 Observational data support the use of ECPR for infants and children in cardiac arrest (especially those with underlying cardiac disease) in the in-hospital critical care setting, when patients are refractory to conventional resuscitation, and when the necessary ECPR protocols, expertise, and equipment exist. 26,27 No evidence exists to support its routine use for cardiac arrest in the out-of-hospital setting.…”