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Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes
Robert M Sutton1, Ron W Reeder2, William P Landis1
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.
Insights
Higher ventilation rates during pediatric cardiopulmonary resuscitation (CPR) were common and associated with improved survival to hospital discharge in critically ill children. This study highlights potential adjustments in ventilation strategies during CPR.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Resuscitation
- Clinical Outcomes Research
Background:
- Ventilation rates during pediatric cardiopulmonary resuscitation (CPR) are critical for patient outcomes but are often not within recommended guidelines.
- Understanding the association between ventilation rates and survival is crucial for optimizing CPR protocols in pediatric intensive care units.
Purpose of the Study:
- To investigate the relationship between ventilation rates during in-hospital CPR and both arterial blood pressure and survival outcomes in intubated children.
- To determine if ventilation rates outside of established guidelines impact patient survival.
Main Methods:
- A prospective, multicenter observational study was conducted in pediatric and pediatric cardiac intensive care units.
- Data on arterial blood pressure and ventilation rates (breaths/min) were extracted from waveforms for intubated children receiving CPR.
- Regression models were used to assess the association between ventilation rates and survival to hospital discharge, controlling for relevant factors.
Main Results:
- The median ventilation rate during CPR events was 29.8 breaths/min, with no events meeting guideline recommendations (10 ± 2 breaths/min).
- High ventilation rates (≥30 breaths/min for <1 year olds, ≥25 breaths/min for older children) were observed in 58% of events.
- Higher ventilation rates were significantly associated with increased survival to hospital discharge (odds ratio, 4.73; p=0.029), even after adjusting for covariates.
Conclusions:
- Ventilation rates exceeding current guidelines are frequently employed during pediatric CPR in intensive care settings.
- Higher ventilation rates, despite being outside recommended ranges, demonstrated a positive association with improved survival to hospital discharge in this cohort.
- These findings suggest a need to re-evaluate current ventilation guidelines during pediatric CPR.
Objectives:
The objective of this study was to associate ventilation rates during in-hospital cardiopulmonary resuscitation with 1) arterial blood pressure during cardiopulmonary resuscitation and 2) survival outcomes.
Design:
Prospective, multicenter observational study.
Setting:
Pediatric and pediatric cardiac ICUs of the Collaborative Pediatric Critical Care Research Network.
Patients:
Intubated children (≥ 37 wk gestation and < 19 yr old) who received at least 1 minute of cardiopulmonary resuscitation.
Interventions:
None.
Measurements And Main Results:
Arterial blood pressure and ventilation rate (breaths/min) were manually extracted from arterial line and capnogram waveforms. Guideline rate was defined as 10 ± 2 breaths/min; high ventilation rate as greater than or equal to 30 breaths/min in children less than 1 year old, and greater than or equal to 25 breaths/min in older children. The primary outcome was survival to hospital discharge. Regression models using Firth penalized likelihood assessed the association between ventilation rates and outcomes. Ventilation rates were available for 52 events (47 patients). More than half of patients (30/47; 64%) were less than 1 year old. Eighteen patients (38%) survived to discharge. Median event-level average ventilation rate was 29.8 breaths/min (interquartile range, 23.8-35.7). No event-level average ventilation rate was within guidelines; 30 events (58%) had high ventilation rates. The only significant association between ventilation rate and arterial blood pressure occurred in children 1 year old or older and was present for systolic blood pressure only (-17.8 mm Hg/10 breaths/min; 95% CI, -27.6 to -8.1; p < 0.01). High ventilation rates were associated with a higher odds of survival to discharge (odds ratio, 4.73; p = 0.029). This association was stable after individually controlling for location (adjusted odds ratio, 5.97; p = 0.022), initial rhythm (adjusted odds ratio, 3.87; p = 0.066), and time of day (adjusted odds ratio, 4.12; p = 0.049).
Conclusions:
In this multicenter cohort, ventilation rates exceeding guidelines were common. Among the range of rates delivered, higher rates were associated with improved survival to hospital discharge.
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