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Deviations from AHA guidelines during pediatric cardiopulmonary resuscitation are associated with decreased event
Heather A Wolfe1, Ryan W Morgan1, Bingqing Zhang1
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
Insights
Deviations from resuscitation guidelines were common in pediatric in-hospital cardiac arrest (IHCA). While circulation deviations (C-DEVs) did not impact survival, they were linked to lower rates of return of spontaneous circulation (ROSC).
Area of Science:
- Pediatric critical care medicine
- Resuscitation science
- Clinical quality improvement
Background:
- Deviations (DEVs) from established resuscitation guidelines are linked to poorer outcomes in adult in-hospital cardiac arrest (IHCA).
- The impact of these deviations on outcomes in pediatric IHCA remains largely unknown.
- Understanding these deviations is crucial for improving pediatric resuscitation protocols.
Purpose of the Study:
- To investigate the association between deviations from resuscitation guidelines and outcomes in pediatric in-hospital cardiac arrest.
- To specifically examine the impact of circulation deviations (C-DEVs) on return of spontaneous circulation (ROSC) and survival to hospital discharge.
- To analyze data from a large, prospectively collected registry to assess these associations.
Main Methods:
- Retrospective cohort study using data from the American Heart Association's Get With The Guidelines-Resuscitation registry (2000-2014).
- Included children with index IHCA of at least 1 minute.
- Defined a composite measure, circulation DEV (C-DEV), encompassing deviations in medications, defibrillation, vascular access, or chest compressions; analyzed using mixed-effect models and propensity score matching.
Main Results:
- Deviations were reported in 17.0% of 7078 pediatric IHCA events; airway and medication deviations were most common.
- Before matching, C-DEVs were associated with decreased ROSC and survival to hospital discharge.
- In the propensity-matched cohort, C-DEVs were associated with decreased ROSC (aOR 0.76) but showed no significant association with survival to hospital discharge (aOR 1.01).
Conclusions:
- Deviations from resuscitation guidelines are frequent in pediatric IHCA.
- In a propensity-matched analysis, circulation deviations (C-DEVs) were linked to reduced likelihood of achieving ROSC.
- Despite the association with ROSC, C-DEVs did not significantly affect survival to hospital discharge in the matched pediatric IHCA cohort.
Background:
Deviations (DEVs) from resuscitation guidelines are associated with worse outcomes after adult in-hospital cardiac arrest (IHCA), but impact during pediatric IHCA is unknown.
Methods:
Retrospective cohort study of prospectively collected data from the American Heart Association's Get With The Guidelines-Resuscitation registry. Children who had an index IHCA of ≥1 min from 2000 to 2014 were included. DEVs are defined by the registry by category (airway, medications, etc.) A composite measure termed circulation DEV(C-DEV), defined as at least one process deviation in the following categories: medications, defibrillation, vascular access, or chest compressions, was the primary exposure variable. Primary outcome was survival to hospital discharge. Mixed-effect models with random intercept for each hospital assessed the relationship of DEVs with survival to hospital discharge. Robustness of findings was assessed via planned secondary analysis using propensity score matching.
Results:
Among 7078 eligible index IHCA events, 1200 (17.0%) had DEVs reported. Airway DEVs (466; 38.8%) and medication DEVs (321; 26.8%) were most common. C-DEVs were present in 629 (52.4%). Before matching, C-DEVs were associated with decreased rate of ROSC (aOR = 0.53, CI95: 0.43-0.64, p < 0.001) and survival to hospital discharge (aOR = 0.71, CI95: 0.60-0.86, p < 0.001). In the matched cohort (C-DEV n = 573, no C-DEV n = 1146), C-DEVs were associated with decreased rate of ROSC (aOR 0.76, CI95 0.60-0.96, p = 0.02), but no association with survival to hospital discharge (aOR 1.01, CI95 0.81-1.25, p = 0.96).
Conclusions:
DEVs were common in this cohort of pediatric IHCA. In a propensity matched cohort, while survival to hospital discharge was similar between groups, events with C-DEVs were less likely to achieve ROSC.
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