IMPORTANCE Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown.OBJECTIVE To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. DESIGN, SETTING. AND PARTICIPANTSWe performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort. EXPOSURE Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine. MAIN OUTCOMES AND MEASURESThe primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale. RESULTS Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01).CONCLUSIONS AND RELEVANCE Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.
Aim Previous studies have examined the association between quantitative computed tomography (CT) measures of cerebral edema and patient outcomes. It has been reported that a calculated gray matter to white matter attenuation ratio (GWR) of < 1.2 indicates a near 100% non-survivable injury post-cardiac arrest. The objective of the current study was to validate whether a GWR < 1.2 reliably indicates poor survival post-cardiac arrest. We also sought to determine the inter-rater variability among reviewers, and examine the utility of a novel GWR measurement to facilitate easier practical use. Methods We performed a retrospective analysis of post-cardiac arrest patients admitted to a single center from 2008 to 2012. Inclusion criteria were age ≥ 18 years, non-traumatic arrest, and available CT imaging within 24 hours after ROSC. Three independent physician reviewers from different specialties measured CT attenuation of pre-specified gray and white matter areas for GWR calculations. Results Out of 171 consecutive patients, 90 met the study inclusion criteria. Thirteen patients were excluded for technical reasons and/or significant additional pathology, leaving 77 head CT scans for evaluation. Median age was 66 years and 63% were male. In-hospital mortality was 65% and 70% of patients received therapeutic hypothermia. For the validation measurement, the intra-class correlation coefficient was 0.70. In our dataset, a GWR below 1.2 did not accurately predict mortality or poor neurological outcome (sensitivity 0.56–0.62 and specificity 0.63–0.81). A score below 1.1 predicted a near 100% mortality but was not a sensitive metric (sensitivity 0.14–0.20 and specificity 0.96–1.00). Similar results were found for the exploratory model. Conclusion A GWR < 1.2 on CT imaging within 24 hours after cardiac arrest was moderately specific for poor neurologic outcome and mortality. Based on our data, a threshold GWR < 1.1 may be a safer cut-off to identify patients with low chance of survival and good neurological outcome. Intra-class correlation among reviewers was moderately good.
IntroductionDextrose may be used during cardiac arrest resuscitation to prevent or reverse hypoglycemia. However, the incidence of dextrose administration during cardiac arrest and the association of dextrose administration with survival and other outcomes are unknown.MethodsWe used the Get With The Guidelines®-Resuscitation national registry to identify adult patients with an in-hospital cardiac arrest between the years 2000 and 2010. To assess the adjusted effects of dextrose administration on survival, we used multivariable regression models with adjustment for multiple patient, event, and hospital characteristics. We performed additional analyses to examine the effects of dextrose on neurological outcome and return of spontaneous circulation.ResultsAmong the 100,029 patients included in our study, 4,189 (4.2%) received dextrose during cardiac arrest resuscitation. The rate of dextrose administration increased during the study period (odds ratio 1.11, 95% confidence interval (CI) 1.09-1.12 per year, P <0.001). Patients who received dextrose during resuscitation had lower rates of survival compared with patients who did not receive dextrose (relative risk 0.88, 95% CI 0.80-0.98, P = 0.02). Administration of dextrose was associated with worse neurological outcome (relative risk 0.88, 95% CI 0.79-0.99, P = 0.03) but an increased chance of return of spontaneous circulation (relative risk 1.07, 95% CI 1.04-1.10, P <0.001).ConclusionsIn this dataset, the administration of dextrose during resuscitation in patients with in-hospital cardiac arrest was found to be associated with a significantly decreased chance of survival and a decreased chance of good neurological outcome.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0867-z) contains supplementary material, which is available to authorized users.
The administration of a single dose of thiamine was associated with a trend toward increase in [Formula: see text]o2 in critically ill patients. There was a significant increase in [Formula: see text]o2 in those patients with preserved or elevated CI. Further study is needed to better characterize the role of thiamine in oxygen extraction. Clinical trial registered with www.clinicaltrials.gov (NCT01462279).
IMPORTANCE-Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. OBJECTIVE-To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest.
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