Inpatient Cardiac Arrest Less Deadly for Kids
Survival after in-hospital cardiac arrest has improved in recent years among pediatric patients, without a worsening of neurological outcomes among the survivors, researchers found.
The risk-adjusted rate of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009, a relative increase of 8% per year (rate ratio 1.08, 95% CI 1.01 to 1.16), according to Saket Girotra, MD, of the University of Iowa Hospitals and Clinics in Iowa City, and colleagues.
At the same time, there was no significant change in the percentage of survivors who had at least severe neurological disability (P=0.32 for trend), the researchers reported online in Circulation: Cardiovascular Quality and Outcomes.
The reasons for the improvement in survival remain unknown, but Girotra and colleagues said it could have to do with a greater emphasis on acute resuscitation in clinical practice guidelines published over the past decade or with hospital-specific quality improvement efforts.
"Initial studies suggest improved patient outcomes with the use of routine mock codes in pediatric hospitals, audiovisual feedback during resuscitation, and post-event debriefing," they wrote. "Additional resuscitation factors such as availability of trained personnel, quality of chest compressions (e.g., depth, rate) with minimal interruptions, better adherence to resuscitation algorithms, and improved coordination between code team members may have played an important role."
In an interview, Girotra said that "The major clinical implication of our findings is the fact that we've been able to benchmark improvement in performance in pediatric resuscitation care over recent years."
"I think future studies are needed to understand which are some of those specific factors that may have been driving this improvement, so that we can expand these processes to all U.S. hospitals," he added.
The researchers examined data from the Get with the Guidelines-Resuscitation registry (formerly known as the National Registry of Cardiopulmonary Resuscitation). They identified 1,031 children at 12 hospitals who had an in-hospital cardiac arrest from Jan. 1, 2000, to Nov. 19, 2009.
The initial rhythm was asystole and pulseless electrical activity in 84.8%, and ventricular fibrillation and pulseless ventricular tachycardia in the rest.
During the study period, there was an increase in the proportion of arrests resulting from pulseless electrical activity (26.6% in the first 4 years of the study to 70.3% in the final 3 years of the study, P<0.001 for trend), resulting in an increase in the proportion of arrests from nonshockable rhythms.
"Although the exact mechanisms behind this changing epidemiology of cardiac arrest rhythms are not clear, it is possible that greater use of minimally invasive approaches in repair of congenital heart disease, advances in intraoperative management of children undergoing cardiac surgery with reduction of ischemia time, and better postoperative management of surgical patients have resulted in a reduction of ventricular fibrillation and pulseless ventricular tachycardia rhythms in this population," the authors wrote.
"At the same time," they continued, "increasing severity of noncardiac illness in pediatric intensive care unit patients may have led to an increase in the proportion of cardiac arrests resulting from nonshockable rhythms, especially pulseless electrical activity. "
Nevertheless, survival to discharge improved over time in this patient population, a trend consistent across age groups and initial rhythms and for both sexes.
The improvement was mostly the result of a better rate of acute resuscitation survival, defined as the return of spontaneous circulation for at least 20 minutes after the initial pulseless arrest. That increased from 42.9% in 2000 to 81.2% in 2009 (P=0.006 for trend).
Post-resuscitation survival -- survival to discharge among the survivors of acute resuscitation -- appeared to increase as well, although the trend did not reach statistical significance (P=0.17), possibly because of a lack of statistical power.
The authors noted some limitations of the study, including the possibility of residual confounding; the lack of information on specific resuscitation variables, delivered treatment, and hospital characteristics; and the ability to look only at unadjusted rates of neurological disability because of a relatively small sample size and some missing data.
It is also possible that the hospitals participating in the registry differ from nonparticipating hospitals, so the findings may not be generalizable to other centers.
Girotra's co-authors reported support from a Career Development Grant Award from the National Heart, Lung, and Blood Institute and a Clinical and Translational Science Award. Get with the Guidelines-Resuscitation is sponsored by the American Heart Association.
The authors reported that they had no conflicts of interest.
From the American Heart Association:
- Cardiac Arrest Updates: Striving to Improve Outcome Factors Impacting Pediatric
- AHA Heart Disease and Stroke Statistics 2013 Update
Primary source: Circulation: Cardiovascular Quality and Outcomes
Source reference:
Girotra S, et al "Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get with the Guidelines-Resuscitation" Circ Cardiovasc Qual Outcomes 2012; DOI: 10.1161/CIRCOUTCOMES.112.967968.
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Todd Neale
Senior Staff Writer
Todd Neale, MedPage Today Staff Writer, got his start in journalism at Audubon Magazine and made a stop in directory publishing before landing at MedPage Today. He received a B.S. in biology from the University of Massachusetts Amherst and an M.A. in journalism from the Science, Health, and Environmental Reporting program at New York University.