Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial

Abstract

Importance: Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes.

Objective: To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings.

Design, setting, and participants: A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021).

Intervention: During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest.

Main outcomes and measures: The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge.

Results: Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47).

Conclusions and relevance: In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU.

Trial registration: ClinicalTrials.gov Identifier: NCT02837497.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Sutton reported receiving grants from the National Institutes of Health (NIH) and serving as a volunteer for the American Heart Association. Dr Morgan reported receiving grant funding from the NIH (K23HL148541) and volunteering for the American Heart Association. Dr Carcillo reported receiving grant funding from the NIH. Dr Carpenter reported receiving grant funding from the NIH. Dr Dean reported receiving grant funding from the NIH. Dr Fink reported receiving grant funding from the NIH and Neurocritical Care Society. Dr Hall reported receiving grant funding from the NIH, serving on the DSMBs of La Jolla Pharmaceuticals and AbbVie, and earing income for licensing from Kiadis. Dr Meert reported receiving grant funding from the NIH. Dr Mourani reported receiving grant funding from the NIH. Dr Pollack reported receiving grant funding from the NIH and from Mallinckrodt Pharmaceuticals, LLC. Dr Wessel reported receiving grant funding from the NIH. Dr Zuppa reported receiving grant funding from the NIH.

Figures

Figure.. Flow of Patients Through the ICU-RESUS Study

aFifteen intensive care units (ICUs) contributed to both intervention and control based on the stepped-wedge design. bEvents could have been excluded for more than 1 reason. cNonindex refers to subsequent cardiopulmonary resuscitation (CPR) events after the first CPR event of a given hospitalization.