Effect of Amplitude Spectral Area on Termination of Fibrillation and Outcomes in Pediatric Cardiac Arrest

Tia T Raymond, Sandeep V Pandit, Heather Griffis, Xuemei Zhang, Richard Hanna, Dana E Niles, Annemarie Silver, Javier J Lasa, Sarah E Haskell, Dianne L Atkins, Vinay M Nadkarni, Pediatric Resuscitation Quality Collaborative (pediRES‐Q) Investigators, Tia T Raymond, Sandeep V Pandit, Heather Griffis, Xuemei Zhang, Richard Hanna, Dana E Niles, Annemarie Silver, Javier J Lasa, Sarah E Haskell, Dianne L Atkins, Vinay M Nadkarni, Pediatric Resuscitation Quality Collaborative (pediRES‐Q) Investigators

Abstract

Background Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and survival in adults but has not been studied in pediatric cardiac arrest. We characterized AMSA during pediatric cardiac arrest from a Pediatric Resuscitation Quality Collaborative and hypothesized that AMSA would be associated with TOF and ROSC. Methods and Results Children aged <18 years with cardiac arrest and ventricular fibrillation were studied. AMSA was calculated for 2 seconds before shock and averaged for each subject (AMSA-avg). TOF was defined as termination of ventricular fibrillation 10 seconds after defibrillation to any non-ventricular fibrillation rhythm. ROSC was defined as >20 minutes without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category were performed. Primary end points were TOF and ROSC. Secondary end points were 24-hour survival and survival to discharge. Between 2015 and 2019, 50 children from 14 hospitals with 111 shocks were identified. In univariate analyses AMSA was not associated with TOF and AMS-Aavg was not associated with ROSC. Multivariable logistic regression showed no association between AMSA and TOF but controlling for defibrillation average current and illness category, there was a trend to significant association between AMSA-avg and ROSC (odds ratio, 1.10 [1.00‒1.22] P=0.058). There was no significant association between AMSA-avg and 24-hour survival or survival to hospital discharge. Conclusions In pediatric patients, AMSA was not associated with TOF, whereas AMSA-avg had a trend to significance for association in ROSC, but not 24-hour survival or survival to hospital discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02708134.

Keywords: cardiopulmonary resuscitation; defibrillation; pediatrics; ventricular fibrillation.

Conflict of interest statement

Niles and Nadkarni disclose that The Children's Hospital of Philadelphia receives support from an unrestricted research grant from ZOLL Medical. Niles and Nadkarni disclose that The Children's Hospital of Philadelphia receives funding from an unrestricted research grant from The American Heart Association. Silver and Pandit are employees of ZOLL Medical Corporation. The remaining authors have no disclosures to report.

Figures

Figure 1. Shock 1 parameters.
Figure 1. Shock 1 parameters.
AMSA indicates amplitude spectral area; and CPR, cardiopulmonary resuscitation.
Figure 2. Patient selection cohort.
Figure 2. Patient selection cohort.
AMSA indicates amplitude spectral area; ECMO, extracorporeal membrane oxygenation; ROC‐ECMO, return of circulation by means of ECMO (extracorporeal membrane oxygenation); ROSC, return of spontaneous circulation; and VF, ventricular fibrillation.
Figure 3. Comparison of AMSA and AMSA‐avg…
Figure 3. Comparison of AMSA and AMSA‐avg in patients with ROSC and TOF compared with those without ROSC and TOF.
A, Patients with ROSC had a median AMSA‐avg of 14.7 mV‐Hz compared with 9.7 mV‐Hz in patients without ROSC (P=0.19). B, Patients with TOF had a median AMSA of 13.4 V‐Hz compared with 8.2 V‐Hz in patients who did not have TOF (P=0.42). C, For AMSA‐avg in ROSC, the area under the curve was 0.61. For a sensitivity of 77% to predict ROSC, the AMSA‐avg threshold was 9.7 mV‐Hz, giving a specificity of 53%, a positive predictive value of 73%, and a negative predictive value of 59%. AMSA indicates amplitude spectral area; AMSA‐avg, amplitude spectral area‐average; ROC, receiver operator curve; ROSC, return of spontaneous circulation; and TOF, termination of fibrillation.
Figure 4. Delta AMSA (dAMSA) in patients…
Figure 4. Delta AMSA (dAMSA) in patients with and without TOF.
A, The dAMSA in 14 patients with ≥2 shocks (11 TOF, 3 no TOF) calculated by subtracting AMSA shock2 from AMSA shock1. Area under the curve for dAMSA is 0.61 and area under the curve for AMSA shock1 is 0.56. B, dAMSA in 22 patients with ≥2 shocks (16 TOF, 6 without TOF) calculated by subtracting AMSA shock2 from AMSA shock1 (consecutive shocks, may or may not be first and second shocks). area under the curve for dAMSA is 0.51 and area under the curve for AMSA at shock1 is 0.72. The odds ratio of shock success was 1.16 for every 1 mV‐Hz increase in AMSA value at first shock (P=0.14). AMSA indicates amplitude spectral area; and TOF, termination of fibrillation.

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