Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States

Abstract

n estimated 15 200 children receive cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest (IHCA) annually in the United States. 1 Pediatric IHCA outcomes improved during the first decade of the 21st century, 2,3 likely owing to a widespread recognition of the need for high-quality resuscitation and a focus on recognizing and transferring the deteriorating pediatric inpatient to an intensive care unit (ICU). However, survival rates have plateaued and more than half of children with IHCA do not survive to hospital discharge. 3 Compared with adults with IHCA, children with IHCA differ in demographic characteristics, location within the hospital, cause of cardiac arrest, initial cardiac arrest rhythm, and type of monitoring in place. [4][5][6][7] Table 1 shows a comparison of these variables between pediatric and adult patients. 3-8 However, prospective pediatric IHCA studies are limited, and most pediatric resuscitation guidelines are extrapolated from adult guidelines. 9,10 Substantial differences also exist between pediatric IHCA and pediatric out-of-hospital cardiac arrest (OHCA). Although IHCA occurrence is frequently associated with the progression of underlying disease processes, such as shock and respiratory failure, common causes of pediatric OHCA include drowning, sudden infant death syndrome, and sudden cardiac death from arrhythmias. 11 Compared with IHCA, OHCA survival outcomes are worse, 12 and OHCA systems of care are focused on encouraging bystander CPR and optimizing basic life support measures in the prehospital state. 13 Pediatric IHCA is a modifiable disease process. Efforts to prevent its occurrence, treat it with high-quality CPR, and deliver successful post-cardiac arrest care can demonstrably improve outcomes. In this narrative review, we discuss pediatric IHCA, including incidence, causes, prevention, treatment, and post-cardiac arrest therapies. MethodsThis narrative review was based on several informal searches of PubMed for peer-reviewed English-language articles related to pediatric IHCA. The searches were conducted between January 4, IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR).OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressio...

Abandon Noninvasive Ventilation in Bronchiolitis? How Unrecognized Bias Can Lead to Problematic Conclusions

“…Finally, the authors report mortality of 0–0.003% in their entire dataset, yet the cardiac arrests that occurred after the admission day were 0.02% for low utilization and 0.36% for high utilization hospitals (1). The rates of IHCA to mortality are very disparate—even if mortality was primarily attributable to IHCA events, the exceedingly high rate of postarrest survival (5) raises concern for misclassification of cardiac arrest.…”

“…The use of noninvasive ventilation in bronchiolitis is widespread, despite limited evidence. Several systematic reviews were unable to conclude from existing literature that noninvasive ventilation reduces invasive ventilation (3)(4)(5). The reviews highlight the lack of studies adequately powered to investigate rare outcomes such as invasive ventilation.…”

Veno-arterial CO2 difference and respiratory quotient after cardiac arrest: An observational cohort study

“…In paediatric cardiac arrests, the most common aetiology is respiratory failure (41). For paediatric IHCAs, haemodynamic deterioration is the second most common reason after hypoxia.…”

“…Consequently, only ~10% of paediatric cardiac arrests present with an initial shockable rhythm (42). A nonshockable rhythm is frequently the presenting rhythm, and for IHCAs, a bradycardia with poor perfusion is the initial rhythm in more than 50% of the events (41,42).…”

Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study

“…The overall incidence rate for out-of-hospital cardiac arrest (OHCA) is 8.3 per 100,000 person-years [6]. In comparison to OHCA, pediatric IHCA has higher rates of survival [6][7][8].…”