Morgann Loaec

Objectives: To develop and internally validate a multivariable prediction model for survival to hospital discharge after pediatric extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest (IHCA), and to use this model to derive risk-standardized survival rates (RSSRs) and quantify between-hospital variation in outcomes. Design: Retrospective multicenter cohort study. Setting: Hospitals contributing to the Extracorporeal Life Support Organization (ELSO) registry between 2020 and 2023. Patients: Children (< 18 yr) treated with ECPR for IHCA. Interventions: None. Measurements and Main Results: Eligible patients were identified from the ELSO Registry and split into derivation ( N = 1060) and validation ( N = 317) cohorts using a hospital-stratified split to preserve within-hospital clustering. Survival prediction models were derived using penalized logistic regression with the least absolute shrinkage and selection operator. A full-event model incorporating 14 routinely available clinical variables demonstrated fair discrimination (area under the curve, 0.728 in the derivation cohort and 0.678 in the validation cohort) and good calibration (observed-to-expected ratio, 0.995; Brier score, 0.222 in the validation cohort). This model was embedded in a multilevel logistic regression model to generate hospital-level RSSRs for centers reporting five or more ECPR cases. Between-hospital variation was quantified using the median odds ratio, which was 1.30 (95% CI, 1.11–1.93), indicating significant differences in survival likelihood between centers after adjusting for patient-level risk. Conclusions: In a large, international cohort of pediatric ECPR patients, we developed and internally validated a clinically interpretable model for survival to hospital discharge. The model performance as a discriminator likely limits its use as a standalone tool for clinical decision-making. However, strong internal calibration allowed for determination of hospital-level RSSRs, which revealed significant inter-hospital variability. These findings demonstrate the feasibility of developing a risk-adjustment model capable of estimating hospital-level RSSRs. Additional external validation and evaluation of residual case-mix differences are needed before such models can be used for benchmarking across pediatric ECPR centers.

OBJECTIVES: Pediatric resuscitation guidelines support using diastolic blood pressure (DBP) as a marker of cardiopulmonary resuscitation (CPR) quality. Thresholds of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children were derived from data limited to the first 10 minutes of CPR, regardless of event duration. We aimed to describe DBP trajectories throughout in-hospital cardiac arrest and evaluate associations between DBP thresholds and return of spontaneous circulation (ROSC) in prolonged CPR (≥ 10 min). DESIGN: Single-center retrospective cohort study (2017–2023). SETTING: PICU and CICU. PATIENTS: Pediatric IHCA with invasive arterial BP monitoring. SETTING AND PATIENTS: Pediatric IHCAs with invasive arterial BP monitoring. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Events with greater than or equal to 1 minute of evaluable DBP data were included in trend analyses; those with greater than or equal to 1 minute of evaluable DBP data after 10 minutes of CPR were included in prolonged CPR analyses. Linear and mixed-effects regression assessed DBP trends; univariate logistic regression evaluated associations between DBP thresholds and ROSC. Among 118 events (median age 0.4 yr; 69% with congenital heart disease), DBP rose early and plateaued above guideline thresholds. Early ROSC was associated with higher average DBP ( p = 0.02) and steeper early DBP rise ( p < 0.001). In 46 prolonged events, 80% had mean DBP above guideline thresholds. In prolonged CPR, an upward DBP trend was associated with ROSC ( p < 0.001). In prolonged CPR, meeting current DBP thresholds was not significantly associated with ROSC, but achieving higher thresholds (≥ 30 mm Hg in infants and ≥ 35 mm Hg in children) later in CPR was associated with ROSC (odds ratio 7.14; 95% CI, 1.58–51.35; p = 0.009). CONCLUSIONS: DBP can be sustained above current thresholds during prolonged CPR. Larger cohort studies are needed to determine if higher, patient-specific, and time-dependent DBP targets are required to achieve ROSC in prolonged CPR.

Aim: To compare post-epinephrine vasopressin administration versus epinephrine and time to return of spontaneous circulation (ROSC) during pediatric in-hospital cardiac arrest (IHCA), and explore vasopressin’s physiologic effects. Methods: This single-center, retrospective cohort study (2017–2023) compared vasopressin patients who received ≥1 dose of preceding epinephrine and matched epinephrine-only patients based on age, illness category, and preceding epinephrine dosing. Time to ROSC was analyzed using Cox regression. Vasopressor response was defined as ≥5 mmHg increase in diastolic blood pressure (DBP). Results: Forty-one matched pairs were analyzed. Median CPR duration was 36.5 [IQR 23, 48] minutes; median time to dose was 14.5 [10.8, 19] minutes. ROSC occurred in 10/41 (24%) vasopressin and 15/41 (36%) epinephrine patients ( p = 0.34) with no difference in time to ROSC (aHR 0.73 [95% CI: 0.31–1.7]). Vasopressor response occurred in 4/12 (33%) vasopressin and 1/7 (14%) epinephrine patients ( p = 0.60). Regression discontinuity analysis demonstrated a change in DBP of +2.3 mmHg after vasopressin (95% CI: −11.4, 16.0) and −5.67 mmHg after epinephrine (–15.13, 3.80). Conclusion: No significant differences were found in time to ROSC or DBP increase between vasopressin and epinephrine given late during CPR. A subset of vasopressin responders suggests further research on intra-arrest DBP response to vasopressin is needed. Impact: The use of intra-arrest vasopressin is an understudied topic in pediatric cardiac arrest. This study presents a unique comparison of ongoing epinephrine to vasopressin administration, using dose matching to address the limitations of our current vasopressin use. We present a novel analysis of physiologic response to vasopressin using the change in diastolic blood pressure.

OBJECTIVES: The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN: Retrospective multicenter cohort study. SETTING: Hospitals contributing data to the American Heart Association’s Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS: Children (p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis (p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84–2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS: ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability).