Ron W. Reeder

BACKGROUND: Hypoplastic left heart syndrome (HLHS) is classified by anatomic subtype: mitral atresia and aortic atresia (MA/AA), mitral stenosis and aortic atresia (MS/AA), and mitral stenosis and aortic stenosis (MS/AS). The MS/AA subtype is associated with ventriculocoronary connections (VCCs). We assessed whether specific HLHS subtypes are associated with an increased risk of mortality and whether this risk is stratified by VCCs identified during fetal or postnatal echocardiography. We also assessed whether the type of neonatal intervention performed modified the risk. METHODS: We performed a multicenter retrospective cohort study of fetuses and infants P =0.784). CONCLUSIONS: In a large, multicenter cohort of HLHS patients, the MS/AA subtype with VCCs had the lowest TFS. Prenatal diagnosis of VCCs was associated with a lower TFS. This study underscores the prognostic value of assessing for VCCs in patients with HLHS both before and after birth.

Objectives: Evaluate the association between cardiopulmonary resuscitation (CPR) ventilation rates and survival to hospital discharge, and identify novel ventilation targets. Design: Multicenter prospective ancillary observational cohort study of the ICU-RESUS trial (NCT02837497). Setting: A total of 18 ICUs from 10 U.S. clinical sites from October 2016 to March 2021. Patients: Hospitalized children (≤ 18 yr) with endotracheal or tracheostomy tubes and evaluable intra-arrest end-tidal carbon dioxide data to calculate ventilation rate. Interventions: None. Measurements and Main Results: Among 234 included events, 86 events (36.8%) had guideline-recommended (20–30 beats per min [bpm]) average ventilation rates during CPR. The association between guideline-recommended CPR ventilation rate and survival to hospital discharge was evaluated with Poisson regression using generalized estimating equations, controlling for a priori covariables (initial pulse status, immediate cause of arrest). We found no association between guideline-recommended ventilation rates and survival to hospital discharge (adjusted relative risk [aRR], 0.95; 95% CI, 0.75–1.21; p = 0.68). In exploratory analyses, novel age-stratified ventilation rates were identified using natural cubic splines and subsequently evaluated in multivariable models. We identified potential thresholds (< 8 yr, ≥ 26 bpm; ≥ 8 yr, < 26 bpm). For children younger than 8 years, average CPR ventilation rate greater than or equal to 26 bpm was associated with improved survival to hospital discharge compared with less than 26 bpm (aRR, 1.32; 95% CI, 1.00–1.73; p = 0.048). Conclusions: CPR ventilation rates in the currently recommended range (20–30 bpm) were not associated with survival in children with in-hospital cardiac arrest. In exploratory analyses in children younger than 8 years, higher ventilation rates (≥ 26 bpm) were associated with improved survival and warrant confirmation in future studies.

BACKGROUND: High-quality cardiopulmonary resuscitation is associated with improved outcomes; however, specific targets for younger age groups are largely based on extrapolations from adult studies and small pediatric cohort studies. METHODS: Prospectively designed embedded study within the ICU RESUScitation Project (ICU-RESUS). Children (≤18 years) who received cardiopulmonary resuscitation in 10 intensive care units in the United States were enrolled between 2016 and 2021. We excluded patients with documented limitations of care, who were brain dead, or who had OHCA. The exposures were American Heart Association-recommended chest compression (CC) targets for rate (100–120 cm ³ /min), depth (≥40 mm for age 80%). Associations between achieving CC targets over the first 10 minutes of cardiopulmonary resuscitation and outcomes were quantified using multivariable Poisson regression models (primary outcome: survival to hospital discharge [SHD]). In exploratory analyses, cubic splines further explored the relationship between CC metrics and outcomes to identify exploratory targets. RESULTS: Among 543 patients with evaluable data, the recommended rate target was met in 46.3%, depth in 25.7%, and CCF in 88.5%. Mean age was 3.6 (SD, 5.3) years, and 54.3% were male. None of these recommended CC targets were associated with SHD (rate: adjusted relative risk [aRR], 0.91 [95% CI, 0.78]; depth: aRR, 0.81 [95% CI, 0.51–1.29]; and CCF: aRR, 1.19 [95% CI, 0.92–1.54], respectively). Using cubic spline analyses, the following exploratory targets were identified and were associated with SHD: rate 130 to 160 cm ³ /min (aRR, 1.23 [95% CI, 1.04–1.46]), depths of 23 to 27 mm for patients 90% (aRR, 1.24 [1.03–1.49]). CONCLUSIONS: Currently recommended CC rate, depth, and fraction targets were not associated with SHD in this cohort. In contrast, we identified new potential pediatric cardiopulmonary resuscitation targets that were associated with SHD: rate 130 to 160 CC/min, depths of 23 to 27 mm for patients 90%. These criteria need validation in future prospective trials. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02837497.

Background Black patients have worse outcomes after in-hospital cardiac arrest (IHCA). Whether these racial disparities are associated with medical emergency team (MET) evaluation prior to IHCA remains unknown. Methods A retrospective cohort study of adults age ≥ 18 years from the American Heart Association Get With The Guidelines® Resuscitation registry who had an IHCA between 2000 and 2021 with acute physiologic decline (modified early warning score [MEWS] ≥ 3) during the 24 hours prior to IHCA. A propensity-weighted cohort was constructed to balance confounders between Black and White patients. The association between race and MET evaluation was quantified with weighted multivariable logistic regression. Results Among 354,480 patients, 88,507 met the initial inclusion criteria, of which 29,714 patients (median age 69 [IQR 58-79] years, 42.5% female, and 26.9% Black) had acute physiologic decline during the 24 hours prior to IHCA. Among patients with acute physiologic decline, 4102 (13.8%) patients had a preceding MET evaluation before IHCA. Rates of MET evaluation prior to cardiac arrest did not differ significantly between Black and White patients with acute physiologic decline (aOR 1.02, 95% CI 0.94-1.11, p = 0.62). Conclusions Though racial disparities in IHCA outcomes exist, this study did not detect a difference in rates of MET evaluation prior to IHCA among patients with acute physiologic decline as a potential mechanism for these disparities. Clinical Perspective What Is New? With the goal to identify potential mechanisms leading to racial disparities in outcomes from adult in-hospital cardiac arrest (IHCA), this multicenter prospective observational study is the first study to analyze the association between race and medical emergency team (MET) evaluation among patients with evidence of clinical deterioration. IHCA We found that rates of MET evaluation among patients with clinical deterioration (i.e., vital sign abnormalities) prior to IHCA did not differ between Black and White patients. What Are the Clinical Implications? These data demonstrate that race is not associated with MET evaluation prior to adult in-hospital cardiac arrest. Future studies should evaluate other links in the American Heart Association’s in-hospital chain of survival (e.g., resuscitation quality, post-arrest care) as potential targets to mitigate racial disparities in IHCA survival.

BACKGROUND: Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide ( ETCO ₂ ) as an indicator of cardiopulmonary resuscitation (CPR) quality, but they note that “specific values to guide therapy have not been established in children.” METHODS: This prospective observational cohort study was a National Heart, Lung, and Blood Institute–funded ancillary study of children in the ICU-RESUS trial (Intensive Care Unit-Resuscitation Project; NCT02837497). Hospitalized children (≤18 years of age and ≥37 weeks postgestational age) who received chest compressions of any duration for cardiopulmonary arrest, had an endotracheal or tracheostomy tube at the start of CPR, and evaluable intra-arrest ETCO ₂ data were included. The primary exposure was event-level average ETCO ₂ during the first 10 minutes of CPR (dichotomized as ≥20 mm Hg versus 2 and outcomes as well as the association between ETCO ₂ and other CPR characteristics: (1) invasively measured systolic and diastolic blood pressures, and (2) CPR quality and chest compression mechanics metrics (ie, time to CPR start; chest compression rate, depth, and fraction; ventilation rate). RESULTS: Among 234 included patients, 133 (57%) had an event-level average ETCO ₂ ≥20 mm Hg. After controlling for a priori covariates, average ETCO ₂ ≥20 mm Hg was associated with a higher incidence of survival to hospital discharge (86/133 [65%] versus 48/101 [48%]; adjusted relative risk, 1.33 [95% CI, 1.04–1.69]; P =0.023) and return of spontaneous circulation (95/133 [71%] versus 59/101 [58%]; adjusted relative risk, 1.22 [95% CI, 1.00–1.49]; P =0.046) compared with lower values. ETCO ₂ ≥20 mm Hg was not associated with survival with favorable neurological outcome or new morbidity among survivors. Average ₂ ≥20 mm Hg was associated with higher systolic and diastolic blood pressures during CPR, lower CPR ventilation rates, and briefer pre-CPR arrest durations compared with lower values. Chest compression rate, depth, and fraction did not differ between ETCO ₂ groups. CONCLUSIONS: In this multicenter study of children with in-hospital cardiopulmonary arrest, ETCO ₂ ≥20 mm Hg was associated with better outcomes and higher intra-arrest blood pressures, but not with chest compression quality metrics.