Rachel Hammond

Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation

AIMnTo determine the association between amiodarone and lidocaine and outcomes in children with cardiac arrest with pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF).nnnBACKGROUNDnCurrent AHA guidelines for CPR and emergency cardiovascular care recommend amiodarone for cardiac arrest in children associated with shock refractory pVT/VF, based on a single pediatric study and extrapolation from adult data.nnnMETHODSnRetrospective cohort study from the Get With the Guidelines-Resuscitation database for in-patient cardiac arrest. Patients<18 years old with pVT/VF cardiac arrest were included. Patients receiving amiodarone or lidocaine prior to arrest or whose initial arrest rhythm was unknown were excluded. Univariate analysis was performed to assess the association between patient and event factors and clinical outcomes. Multivariate analysis was performed to address independent association between lidocaine and amiodarone use and outcomes.nnnRESULTSnOf 889 patients, 171 (19%) received amiodarone, 295 (33%) received lidocaine, and 82 (10%) received both. Return of spontaneous circulation (ROSC) occurred in 484/889 (54%), 24-h survival in 342/874 (39%), and survival to hospital discharge in 194/889 (22%). Lidocaine was associated with improved ROSC (adjusted OR 2.02, 95% CI 1.36-3), and 24-h survival (adjusted OR 1.66, 95% CI 1.11-2.49), but not hospital discharge. Amiodarone use was not associated with ROSC, 24h survival, or survival to discharge.nnnCONCLUSIONSnFor children with in-hospital pVT/VF, lidocaine use was independently associated with improved ROSC and 24-h survival. Amiodarone use was not associated with superior rates of ROSC, survival at 24h. Neither drug was associated with survival to hospital discharge.

Association of Left Ventricular Systolic Function and Vasopressor Support With Survival Following Pediatric Out-of-Hospital Cardiac Arrest*

Objectives: To characterize the association of hospital discharge survival with left ventricular systolic function evaluated by transthoracic echocardiography and vasoactive infusion support following return of spontaneous circulation after pediatric out-of-hospital cardiac arrest. Design: Retrospective case series. Setting: Single-center tertiary care pediatric cardiac arrest and critical care referral center. Patients: Consecutive out-of-hospital cardiac arrest patients less than 18 years surviving to PICU admission who had a transthoracic echocardiography obtained by the clinical team within 24 hours of admission from January 2006 to May 2012. Interventions: None. Measurements and Main Results: Fifty-eight patients had a post–return of spontaneous circulation transthoracic echocardiography performed within 24 hours of admission. The median time from return of spontaneous circulation to echo was 6.5 hours (interquartile range, 4.7, 15.0 hr). Left ventricular systolic function was decreased in 24 of 58 patients (41%). The mortality rate was 67% (39 of 58). Thirty-six patients (62%) received vasoactive infusions at the time of transthoracic echocardiography, and increased vasopressor inotropic score was associated with increased mortality on univariate analysis (p < 0.001). After controlling for defibrillation, vasopressor inotropic score, and interaction between vasopressor inotropic score and left ventricular systolic function, decreased left ventricular systolic function was associated with increased mortality (odds ratio, 13.7; 95% CI, 1.54–122). Conclusions: In patients receiving transthoracic echocardiography within the first 24 hours following return of spontaneous circulation after pediatric out-of-hospital cardiac arrest, decreased left ventricular systolic function and vasopressor use were common. Decreased left ventricular systolic function was associated with increased mortality.

Lung transplant waitlist mortality: height as a predictor of poor outcomes.

The LAS was designed to minimize pretransplant mortality while maximizing post‐transplant outcome. Recipients <12 are not allocated lungs based on LAS. Waitlist mortality has decreased for those >12, but not <12, suggesting this population may be disadvantaged. To identify predictors of waitlist mortality, a retrospective analysis of the UNOS database was performed since implementation of the LAS. There were 16 973 patients listed for lung transplant in the United States; 12 070 (71.1%) were transplanted, and 2498 (14.7%) patients died or were removed from the wait list. Significantly more pediatric patients died or were removed compared with adults (22.0% vs. 14.4%, p < 0.01). In multivariate analysis, in addition to higher LAS at time of listing (adj. HR1.058, 1.055–1.060), shorter height (1.008, 1.006–1.010), male gender (1.210, 1.110–1.319), and requiring ECMO (1.613, 1.202–2.163) were associated with pretransplant mortality. Post‐transplant survival was not affected by height. The current age cutoff may impose limitations within the current lung allocation system in the United States. Height is an independent predictor of waitlist mortality and may be a valuable factor for the development of a comprehensive lung allocation system.

Neuroprognostication After Pediatric Cardiac Arrest

BACKGROUNDnManagement decisions and parental counseling after pediatric cardiac arrest depend on the ability of physicians to make accurate and timely predictions regarding neurological recovery. We evaluated neurologists and intensivists performing neuroprognostication after cardiac arrest to determine prediction agreement, accuracy, and confidence.nnnMETHODSnPediatric neurologists (n = 10) and intensivists (n = 9) reviewed 18 cases of children successfully resuscitated from a cardiac arrest and managed in the pediatric intensive care unit. Cases were sequentially presented (after arrest day 1, days 2-4, and days 5-7), with updated examinations, neurophysiologic data, and neuroimaging data. At each time period, physicians predicted outcome by Pediatric Cerebral Performance Category and specified prediction confidence.nnnRESULTSnPredicted discharge Pediatric Cerebral Performance Category versus actual hospital discharge Pediatric Cerebral Performance Category outcomes were compared. Exact (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = 0) and close (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = ±1) outcome prediction accuracies for all physicians improved over successive periods (P < 0.05). Prediction accuracy did not differ significantly between physician groups at any period or overall. Agreement improved over time among neurologists (day 1 Kappa [κ], 0.28; days 2-4 κ, 0.43; days 5-7 κ, 0.68) and among intensivists (day 1 κ, 0.30; days 2-4 κ, 0.44; days 5-7 κ, 0.57). Prediction confidence increased over time (P < 0.001) and did not differ between physician groups.nnnCONCLUSIONSnInter-rater agreement among neurologists and among intensivists improved over time and reached moderate levels. For all physicians, prediction accuracy and confidence improved over time. Further prospective research is needed to better characterize how physicians objectively and subjectively estimate neurological recovery after acute brain injury.