Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study

Abstract

ObjeCtivesTo evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation. DesignNationwide retrospective cohort study.setting Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands. PartiCiPantsChildren aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care. Main OutCOMe MeasureSurvival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥ 4).results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥ 4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤ 3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome. COnClusiOnsDrowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

Part 3: Adult Basic Life Support and Automated External Defibrillation

“…53,54,57,59,60,74,75,79,80 All studies noted worse outcomes among patients with prolonged submersion durations compared with intermediate submersion durations (RRs ranged between 0.02 53 and 0.45 60,75 53 Water temperatures were measured within a month of the drowning incident. Univariate analysis according to temperatures less than or greater than 6°C or less than or greater than 16°C found no difference in neurologic survival: RR, 1.11 (95% CI, 0.9-1.37); RR, 1.02 (95% CI, 0.81-1.27); absolute difference, −0.5% (−7.5% to 6.1%), respectively.…”

“…[53][54][55][57][58][59][60][61]64,[74][75][76] All studies noted worse outcomes among patients with submersion durations exceeding 5 minutes (RRs ranged between 0.05 53 and 0.61 60 ). The 713/826 patients (86.3%) who had outcome information available and were submerged for short durations had good outcomes compared to 128/1150 (11%) with longer submersion durations.…”

“…The systematic review included observational studies with control groups, which presented data enabling us to calculate RRs or reported ORs for the following prognostic factors: (1) 53,54 The populations evaluated varied between studies and included emergency service data, coroners' registries, emergency department, and intensive care admissions.…”

“…It is possible that outcomes may have changed over time, although this was not observed in the 2 studies that evaluated outcomes over time. 53,54 The populations evaluated varied between studies and included emergency service data, coroners' registries, emergency department, and intensive care admissions. …”

Should we try longer? Duration of cardiopulmonary resuscitation in the Emergency Department and association with survival

“…Other patient populations may be much less likely to recover after prolonged resuscitation, as illustrated in an observational study of pediatric drowning victims, where survival rates if CPR >30 min was required were essentially zero. 4 In a prospective observational study of adult patients who obtained ROSC after out-of-hospital arrest and were treated with therapeutic hypothermia, longer downtime was associated with worse prognosis, but even in those with downtime >20 min, 23% had a good neurologic outcome. 5 Clearly, these studies are each looking at different patient groups, and longer downtime for an individual remains a poor prognostic indicator.…”