Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis
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Published on: April 7, 2023
Shairbanu S Zinna1, Ryan W Morgan1, Ron W Reeder2
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
Insights
Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. A pre-CPR pulse pressure ≥20 mmHg was associated with improved patient outcomes, including return of spontaneous circulation and survival to hospital discharge with favorable neurologic outcome.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Emergency Medicine
- Cardiovascular Physiology
Background:
- Current pediatric cardiopulmonary resuscitation (CPR) guidelines suggest initiating CPR for heart rates (HRs) below 60 beats per minute (bpm) accompanied by poor perfusion.
- Differentiating between bradycardia with poor perfusion (BRADY) and pulseless electrical activity (PEA) is crucial for guiding resuscitation efforts.
Purpose of the Study:
- To compare pre-CPR heart rates (HRs) and arterial blood pressures (BPs) between pediatric patients with BRADY and PEA.
- To investigate the association between pre-CPR hemodynamic parameters and patient outcomes, including return of spontaneous circulation (ROSC) and survival.
Main Methods:
- A prospective observational cohort study analyzing data from the ICU-RESUScitation trial.
- Hemodynamic data (HR, BP) were collected in the 15 seconds and two minutes prior to CPR, stratified by age (≤1 year and >1 year).
- Poisson regression models were used to assess the relationship between pre-CPR hemodynamics and outcomes.
Main Results:
- Pre-CPR HRs were significantly lower in the BRADY group compared to the PEA group across both age strata.
- Pre-CPR pulse pressure was higher in the BRADY group than in the PEA group.
- A pre-CPR pulse pressure ≥20 mmHg was associated with higher rates of ROSC in PEA patients and improved survival to hospital discharge with favorable neurologic outcome in both BRADY and PEA groups.
Conclusions:
- Pre-CPR pulse pressure, particularly ≥20 mmHg, is a valuable indicator associated with improved outcomes in pediatric patients undergoing CPR.
- While pre-CPR HRs differ between BRADY and PEA, a threshold of <60 bpm was not independently associated with outcomes.
- Clinical assessment of pulse pressure may aid in risk stratification and treatment decisions prior to and during pediatric CPR.
Aim:
Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes.
Methods And Results:
Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes.
Conclusions:
Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.
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