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

Robert M. Sutton, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Heather A. Wolfe, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Ron W. Reeder, Department of Pediatrics, University of Utah, Salt Lake City.
Tageldin Ahmed, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit.
Robert Bishop, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora.
Matthew Bochkoris, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania.
Candice Burns, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri.
J Wesley Diddle, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC.
Myke Federman, Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles.
Richard Fernandez, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus.
Deborah Franzon, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco.
Aisha H. Frazier, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware.
Stuart H. Friess, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri.
Kathryn Graham, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
David Hehir, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Christopher M. Horvat, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania.
Leanna L. Huard, Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles.
William P. Landis, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Tensing Maa, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus.
Arushi Manga, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri.
Ryan W. Morgan, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Vinay M. Nadkarni, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Maryam Y. Naim, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia.
Chella A. Palmer, Department of Pediatrics, University of Utah, Salt Lake City.
Carleen Schneiter

Document Type

Journal Article

Publication Date

3-8-2022

Journal

JAMA

Volume

327

Issue

10

DOI

10.1001/jama.2022.1738

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.

Department

Pediatrics

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