Association Between Time to Defibrillation and Survival in Pediatric In-Hospital Cardiac Arrest With a First Documented Shockable Rhythm

Elizabeth A Hunt, Jordan M Duval-Arnould, Melania M Bembea, Tia Raymond, Aaron Calhoun, Dianne L Atkins, Robert A Berg, Vinay M Nadkarni, Michael Donnino, Lars W Andersen, American Heart Association’s Get With The Guidelines–Resuscitation Investigators, Elizabeth A Hunt, Jordan M Duval-Arnould, Melania M Bembea, Tia Raymond, Aaron Calhoun, Dianne L Atkins, Robert A Berg, Vinay M Nadkarni, Michael Donnino, Lars W Andersen, American Heart Association’s Get With The Guidelines–Resuscitation Investigators

Abstract

Importance: Delayed defibrillation (>2 minutes) in adult in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Little is known about the timing and outcomes of defibrillation in pediatric IHCA.

Objective: To determine whether time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm is associated with survival to hospital discharge.

Design, setting, and participants: In this cohort study, data were obtained from the Get With The Guidelines-Resuscitation national registry between January 1, 2000, and December 31, 2015, and analyses were completed by October 1, 2017. Participants were pediatric patients younger than 18 years with an IHCA and a first documented rhythm of pulseless ventricular tachycardia or ventricular fibrillation and at least 1 defibrillation attempt.

Exposures: Time between loss of pulse and first defibrillation attempt.

Main outcomes and measures: The primary outcome was survival to hospital discharge. Secondary outcomes were return of circulation, 24-hour survival, and favorable neurologic outcome at hospital discharge.

Results: Among 477 patients with a pulseless shockable rhythm (median [interquartile range] age, 4 years [3 months to 14 years]; 285 [60%] male), 338 (71%) had a first defibrillation attempt at 2 minutes or less after pulselessness. Children were less likely to be shocked in 2 minutes or less for ward vs intensive care unit IHCAs (48% [11 of 23] vs 72% [268 of 371]; P = .01]). Thirty-eight percent (179 patients) survived to hospital discharge. The median (interquartile range) reported time to first defibrillation attempt was 1 minute (0-3 minutes) in both survivors and nonsurvivors. Time to first defibrillation attempt was not associated with survival in unadjusted analysis (risk ratio [RR] per minute increase, 0.96; 95% CI, 0.92-1.01; P = .15) or adjusted analysis (RR, 0.99; 95% CI, 0.94-1.06; P = .86). There was no difference in survival between those with a first defibrillation attempt in 2 minutes or less vs more than 2 minutes in unadjusted analysis (132 of 338 [39%] vs 47 of 139 [34%]; RR, 0.87; 95% CI, 0.66-1.13; P = .29) or multivariable analysis (RR, 0.99; 95% CI, 0.75-1.30; P = .93). Time to first defibrillation attempt was also not associated with secondary outcome measures.

Conclusions and relevance: In contrast to published adult IHCA and pediatric out-of-hospital cardiac arrest data, no significant association was observed between time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm and survival to hospital discharge.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hunt has received grant funding from the National Institutes of Health that is unrelated to this study. Dr Hunt has received honoraria and reimbursement of travel expenses from Zoll Medical Corporation for speaking engagements on the topic of an educational innovation she created. In addition, Zoll Medical Corporation has a nonexclusive license for the use of educational technology on which Drs Hunt and Duval-Arnould have patents issued. Dr Raymond reported personal fees from Zoll Medical outside the submitted work. Dr Donnino reported grants from the National Heart, Lung, and Blood Institute during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Patient Inclusion and Exclusion Criteria
Figure 1.. Patient Inclusion and Exclusion Criteria
Of 17 771 pediatric IHCA events, 477 were included in the study. IHCA indicates in-hospital cardiac arrest; pVT, pulseless ventricular tachycardia; VF, ventricular fibrillation.
Figure 2.. Distribution of Time to First…
Figure 2.. Distribution of Time to First Defibrillation Attempt
Proportion of study participants per 1 minute elapsed between loss of pulse and time to first defibrillation attempt.
Figure 3.. Survival According to Minute of…
Figure 3.. Survival According to Minute of First Defibrillation Attempt
Percentage of patients (with 95% confidence intervals [error bars]) who survived to hospital discharge for each 1 minute elapsed between loss of pulse and time to first defibrillation attempt.

References

    1. Knudson JD, Neish SR, Cabrera AG, et al. . Prevalence and outcomes of pediatric in-hospital cardiopulmonary resuscitation in the United States: an analysis of the Kids’ Inpatient Database. Crit Care Med. 2012;40(11):-. doi:10.1097/CCM.0b013e31825feb3f
    1. Morrison LJ, Neumar RW, Zimmerman JL, et al. ; American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease . Strategies for improving survival after in-hospital cardiac arrest in the United States: 2013 consensus recommendations: a consensus statement from the American Heart Association. Circulation. 2013;127(14):1538-1563. doi:10.1161/CIR.0b013e31828b2770
    1. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26. doi:10.1001/archinternmed.2009.424
    1. Cheng A, Brown LL, Duff JP, et al. ; International Network for Simulation-Based Pediatric Innovation, Research, & Education (INSPIRE) CPR Investigators . Improving cardiopulmonary resuscitation with a CPR feedback device and refresher simulations (CPR CARES Study): a randomized clinical trial. JAMA Pediatr. 2015;169(2):137-144. doi:10.1001/jamapediatrics.2014.2616
    1. McInnes AD, Sutton RM, Orioles A, et al. . The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents. Resuscitation. 2011;82(8):1025-1029. doi:10.1016/j.resuscitation.2011.03.020
    1. Hunt EA, Vera K, Diener-West M, et al. . Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests. Resuscitation. 2009;80(7):819-825. doi:10.1016/j.resuscitation.2009.03.020
    1. Sutton RM, Niles D, Nysaether J, et al. . Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009;124(2):494-499. doi:10.1542/peds.2008-1930
    1. Jayaram N, Spertus JA, Nadkarni V, et al. ; American Heart Association’s Get With the Guidelines–Resuscitation Investigators . Hospital variation in survival after pediatric in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 2014;7(4):517-523. doi:10.1161/CIRCOUTCOMES.113.000691
    1. Khera R, Chan PS, Donnino M, Girotra S; American Heart Association’s Get With The Guidelines–Resuscitation Investigators . Hospital variation in time to epinephrine for nonshockable in-hospital cardiac arrest. Circulation. 2016;134(25):2105-2114. doi:10.1161/CIRCULATIONAHA.116.025459
    1. Chan PS, Nichol G, Krumholz HM, Spertus JA, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) Investigators . Hospital variation in time to defibrillation after in-hospital cardiac arrest. Arch Intern Med. 2009;169(14):1265-1273. doi:10.1001/archinternmed.2009.196
    1. Moler FW, Meert K, Donaldson AE, et al. ; Pediatric Emergency Care Applied Research Network . In-hospital versus out-of-hospital pediatric cardiac arrest: a multicenter cohort study. Crit Care Med. 2009;37(7):2259-2267. doi:10.1097/CCM.0b013e3181a00a6a
    1. Berg RA, Nadkarni VM, Clark AE, et al. ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network . Incidence and outcomes of cardiopulmonary resuscitation in PICUs. Crit Care Med. 2016;44(4):798-808.
    1. Del Castillo J, López-Herce J, Matamoros M, et al. ; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI . Long-term evolution after in-hospital cardiac arrest in children: prospective multicenter multinational study. Resuscitation. 2015;96:126-134. doi:10.1016/j.resuscitation.2015.07.037
    1. Del Castillo J, López-Herce J, Cañadas S, et al. ; Iberoamerican Pediatric Cardiac Arrest Study Network RIBEPCI . Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study. Resuscitation. 2014;85(10):1380-1386. doi:10.1016/j.resuscitation.2014.06.024
    1. Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA; American Heart Association National Registry of CPR Investigators . Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354(22):2328-2339. doi:10.1056/NEJMoa052917
    1. Nadkarni VM, Larkin GL, Peberdy MA, et al. ; National Registry of Cardiopulmonary Resuscitation Investigators . First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295(1):50-57. doi:10.1001/jama.295.1.50
    1. Chameides L, Brown GE, Raye JR, Todres DI, Viles PH. Guidelines for defibrillation in infants and children. report of the American Heart Association target activity group: cardiopulmonary resuscitation in the young. Circulation. 1977;56(3):502A-503A.
    1. Maconochie IK, Bingham R, Eich C, et al. ; Paediatric Life Support Section Collaborators . European Resuscitation Council Guidelines for Resuscitation 2015: section 6, paediatric life support. Resuscitation. 2015;95:223-248. doi:10.1016/j.resuscitation.2015.07.028
    1. de Caen AR, Berg MD, Chameides L, et al. . 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care: part 12: pediatric advanced life support. Circulation. 2015;132(18)(suppl 2):S526-S542. doi:10.1161/CIR.0000000000000266
    1. Chan PS, Krumholz HM, Nichol G, Nallamothu BK; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators . Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467
    1. American Heart Association Resuscitation fact sheet. . Published May 2017. Accessed October 31, 2017.
    1. Hunt EA, Walker AR, Shaffner DH, Miller MR, Pronovost PJ. Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes. Pediatrics. 2008;121(1):e34-e43. doi:10.1542/peds.2007-0029
    1. Peberdy MA, Kaye W, Ornato JP, et al. . Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58(3):297-308. doi:10.1016/S0300-9572(03)00215-6
    1. Perkins GD, Jacobs IG, Nadkarni VM, et al. ; Utstein Collaborators . Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry templates for out-of-hospital cardiac arrest. Resuscitation. 2015;96:328-340. doi:10.1016/j.resuscitation.2014.11.002
    1. Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr. 1992;121(1):68-74. doi:10.1016/S0022-3476(05)82544-2
    1. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, Brodie-Fowler M. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med. 2000;28(7):2616-2620. doi:10.1097/00003246-200007000-00072
    1. Andersen LW, Raymond TT, Berg RA, et al. ; American Heart Association’s Get With The Guidelines–Resuscitation Investigators . Association between tracheal intubation during pediatric in-hospital cardiac arrest and survival. JAMA. 2016;316(17):1786-1797. doi:10.1001/jama.2016.14486
    1. Zou G. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702-706. doi:10.1093/aje/kwh090
    1. Zou GY, Donner A. Extension of the modified Poisson regression model to prospective studies with correlated binary data. Stat Methods Med Res. 2013;22(6):661-670. doi:10.1177/0962280211427759
    1. Andersen LW, Berg KM, Saindon BZ, et al. ; American Heart Association Get With the Guidelines–Resuscitation Investigators . Time to epinephrine and survival after pediatric in-hospital cardiac arrest. JAMA. 2015;314(8):802-810. doi:10.1001/jama.2015.9678
    1. Meaney PA, Nadkarni VM, Cook EF, et al. ; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators . Higher survival rates among younger patients after pediatric intensive care unit cardiac arrests. Pediatrics. 2006;118(6):2424-2433. doi:10.1542/peds.2006-1724
    1. Donoghue AJ, Nadkarni VM, Elliott M, Durbin D; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators . Effect of hospital characteristics on outcomes from pediatric cardiopulmonary resuscitation: a report from the National Registry of Cardiopulmonary Resuscitation. Pediatrics. 2006;118(3):995-1001. doi:10.1542/peds.2006-0453
    1. Ortmann L, Prodhan P, Gossett J, et al. ; American Heart Association’s Get With the Guidelines–Resuscitation Investigators . Outcomes after in-hospital cardiac arrest in children with cardiac disease: a report from Get With the Guidelines–Resuscitation. Circulation. 2011;124(21):2329-2337. doi:10.1161/CIRCULATIONAHA.110.013466
    1. Herlitz J, Aune S, Bång A, et al. . Very high survival among patients defibrillated at an early stage after in-hospital ventricular fibrillation on wards with and without monitoring facilities. Resuscitation. 2005;66(2):159-166. doi:10.1016/j.resuscitation.2005.03.018
    1. Mitani Y, Ohta K, Yodoya N, et al. . Public access defibrillation improved the outcome after out-of-hospital cardiac arrest in school-age children: a nationwide, population-based, Utstein Registry study in Japan. Europace. 2013;15(9):1259-1266. doi:10.1093/europace/eut053
    1. Yakaitis RW, Ewy GA, Otto CW, Taren DL, Moon TE. Influence of time and therapy on ventricular defibrillation in dogs. Crit Care Med. 1980;8(3):157-163. doi:10.1097/00003246-198003000-00014
    1. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96(10):3308-3313. doi:10.1161/01.CIR.96.10.3308
    1. Berg RA, Sutton RM, Holubkov R, et al. ; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network; American Heart Association Get With the Guidelines–Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators . Ratio of PICU versus ward cardiopulmonary resuscitation events is increasing. Crit Care Med. 2013;41(10):2292-2297. doi:10.1097/CCM.0b013e31828cf0c0
    1. Weisfeldt ML, Becker LB. Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002;288(23):3035-3038. doi:10.1001/jama.288.23.3035
    1. O’Leary FM. Paediatric resuscitation training: is e-learning the answer? a before and after pilot study. J Paediatr Child Health. 2012;48(6):529-533. doi:10.1111/j.1440-1754.2011.02250.x
    1. O’Leary FM, Janson P. Can e-learning improve medical students’ knowledge and competence in paediatric cardiopulmonary resuscitation? a prospective before and after study. Emerg Med Australas. 2010;22(4):324-329. doi:10.1111/j.1742-6723.2010.01302.x
    1. Shilkofski NA, Nelson KL, Hunt EA. Recognition and treatment of unstable supraventricular tachycardia by pediatric residents in a simulation scenario. Simul Healthc. 2008;3(1):4-9. doi:10.1097/SIH.0b013e31815bfa4e
    1. Kaye W, Mancini ME, Truitt TL. When minutes count—the fallacy of accurate time documentation during in-hospital resuscitation. Resuscitation. 2005;65(3):285-290. doi:10.1016/j.resuscitation.2004.12.020
    1. Peace JM, Yuen TC, Borak MH, Edelson DP. Tablet-based cardiac arrest documentation: a pilot study. Resuscitation. 2014;85(2):266-269. doi:10.1016/j.resuscitation.2013.10.013
    1. Grigg E, Palmer A, Grigg J, et al. . Randomised trial comparing the recording ability of a novel, electronic emergency documentation system with the AHA paper cardiac arrest record. Emerg Med J. 2014;31(10):833-839. doi:10.1136/emermed-2013-202512
    1. Frisch A, Reynolds JC, Condle J, Gruen D, Callaway CW. Documentation discrepancies of time-dependent critical events in out of hospital cardiac arrest. Resuscitation. 2014;85(8):1111-1114. doi:10.1016/j.resuscitation.2014.05.002
    1. Siems A, Tomaino E, Watson A, Spaeder MC, Su L. Improving quality in measuring time to initiation of CPR during in-hospital resuscitation. Resuscitation. 2017;118:15-20. doi:10.1016/j.resuscitation.2017.06.018
    1. Rothman J, Greenland S, Lash T. Modern Epidemiology. 3rd ed Philadelphia, PA: Lippincott Williams and Wilkins; 2008.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe