Outcomes of pediatric patients with COVID-19 and in-hospital cardiopulmonary resuscitation.

BACKGROUND: Early studies found low survival rates for adults with COVID-19 infection and in-hospital cardiac arrest (IHCA). We evaluated the association of COVID-19 infection on survival outcomes in pediatric patients undergoing cardiopulmonary resuscitation (CPR). METHODS: Within Get-With-The-Guidelines®-Resuscitation, we identified pediatric patients who underwent CPR for an IHCA or bradycardia with poor perfusion between March and December, 2020. We compared survival outcomes (survival to discharge and return of spontaneous circulation for ≥20 minutes [ROSC]) between patients with suspected/confirmed COVID-19 infection and non-COVID-19 patients using multivariable hierarchical regression, with hospital site as a random effect and patient and cardiac arrest variables with a significant (p < 0.05) bivariate association as fixed effects. RESULTS: Overall, 1328 pediatric in-hospital CPR events were identified (590 IHCA, 738 bradycardia with poor perfusion), of which 46 (32 IHCA, 14 bradycardia) had suspected/confirmed COVID-19 infection. Rates of survival to discharge were similar between those with and without COVID-19 infection (39.1% vs. 44.9%; adjusted RR, 1.14 [95% CI: 0.55-2.36]), and these estimates were similar for those with IHCA and bradycardia with poor perfusion (adjusted RRs of 1.03 and 1.05; interaction p = 0.96). Rates of ROSC were also similar between pediatric patients with and without COVID-19 overall (67.4% vs. 76.9%; adjusted RR, 0.87 [0.43, 1.77]), and for the subgroups with IHCA or bradycardia requiring CPR (adjusted RRs of 0.95 and 0.86, interaction p = 0.26). CONCLUSIONS: In a large multicenter national registry of CPR events, COVID-19 infection was not associated with lower rates of ROSC or survival to hospital discharge in pediatric patients undergoing CPR.

Implications of a recurrent in-hospital cardiac arrest on survival and neurological outcomes.

BACKGROUND: Despite the high incidence of in-hospital cardiac arrest (IHCA) in US hospitals, the prognosis and end-of-life decision-making patterns of a patient with a recurrent IHCA are unknown. METHODS: Within Get-With-The-Guidelines-Resuscitation, we identified 192,250 patients from 711 hospitals with an IHCA from 2000 to 2015. Patients were categorized as having no recurrent IHCA (only 1 event), recurrent IHCA (≥2 IHCAs), and recurrent out-of-hospital cardiac arrest (OHCA), defined as an IHCA after an OHCA. Using multivariable hierarchical logistic regression, rates of survival to discharge and favorable neurological survival (mild or no disability) between the 3 groups were compared. Rates of de novo "do not attempt resuscitation" (DNAR) and withdrawal of care orders among successfully resuscitated patients were also evaluated. RESULTS: Overall, 165,446 (86.1%) had no recurrent IHCA, 23,643 (12.3%) had recurrent IHCA, and 3162 (1.6%) had recurrent OHCA. Compared with patients with no recurrent IHCA, patients with recurrent IHCA were less than half as likely to survive to discharge (12.7% vs 22.1%; adjusted OR: 0.46 [0.44-0.48], P < .001) and have favorable neurological survival (7.0% vs 13.1%; adjusted OR: 0.44 [0.42-0.47], P < .001). Compared with patients with recurrent OHCA, patients with recurrent IHCA also had lower rates of survival to discharge (12.7% vs 16.1%; adjusted OR: 0.81 [0.71-0.94], P = .005) and favorable neurological survival (7.0% vs 8.9%; adjusted OR: 0.66 [0.54-0.81], P < .001). Despite worse survival outcomes, patients with recurrent IHCA were least likely to adopt DNAR orders within the first 24 hours after successful resuscitation compared with patients with no recurrent IHCA or recurrent OHCA (17.2% vs 18.9% and 26.6%, respectively) or withdraw care at any time (17.7% vs 24.4% and 31.2%, respectively). CONCLUSIONS: Nearly 1 in 8 patients with an IHCA has a recurrent IHCA, and these patients have worse outcomes than patients with only a single IHCA and those with an IHCA after being hospitalized for an OHCA. Despite worse survival, rates of DNAR and withdrawal of care were lowest for patients with recurrent IHCA. These findings provide important prognostic information for clinicians caring for patients with recurrent IHCA and suggest the need to better align resuscitation and end-of-life decisions with patients' prognoses after IHCA.

Frequency of medical emergency team activation prior to pediatric cardiopulmonary resuscitation.

BACKGROUND: Medical Emergency Teams (METs) are designed to respond to signs of clinical decline in order to prevent cardiopulmonary arrest and reduce mortality. The frequency of MET activation prior to pediatric cardiopulmonary resuscitation (CPR) is unknown. METHODS: Within the Get With The Guidelines-Resuscitation Registry (GWTG-R), we identified children with bradycardia or cardiac arrest requiring CPR on the general inpatient or telemetry floors from 2007 to 2013. We examined the frequency with which CPR outside the ICU was preceded by a MET evaluation. In cases where MET evaluation did not occur, we examined the frequency of severely abnormal vital signs at least 1hour prior to CPR that could have prompted a MET evaluation but did not. RESULTS: Of 215 children from 23 hospitals requiring CPR, 48 (22.3%) had a preceding MET evaluation. Children with MET evaluation prior to CPR were older (6.8±6.5 vs. 3.1±4.7 years of age, p<0.001) and were more likely to have metabolic/electrolyte abnormalities (18.8% vs. 5.4%, p=0.006), sepsis (16.7% vs. 4.8%, p=0.01), or malignancy (22.9% vs. 5.4%, p<0.001). Among patients who did not have a MET called and with information on vital signs, 55/141 (39.0%) had at least one abnormal vital sign that could have triggered a MET. CONCLUSION: The majority of pediatric patients requiring CPR for bradycardia or cardiac arrest do not have a preceding MET evaluation despite a significant number meeting criteria that could have triggered the MET. This suggests opportunities to more efficiently use MET teams in routine care.

Missed opportunities in use of medical emergency teams prior to in-hospital cardiac arrest.

BACKGROUND: Hospitals often employ Medical Emergency Teams (METs) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ≥1 hour preceding cardiac arrest. METHODS: Within Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least 1 severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated. RESULTS: Overall, few (3,814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median, 14.6% [interquartile range, 9.1%-22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5,243 (40.0%), 4,078 (31.1%), and 1,767 (13.4%) had at least 1 severe vital sign abnormality ≥1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P = .04] and -0.16 [P = .01], respectively). CONCLUSIONS: Although METs are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use METs in current practice.