Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest

Andersen, Lars W.; Berg, Katherine M.; Saindon, Brian Z; Massaro, Joseph M.; Raymond, Tia T.; Berg, Robert A.; Nadkarni, Vinay; Donnino, Michael W.

doi:10.1001/jama.2015.9678

Cited by 174 publications

(142 citation statements)

References 42 publications

(48 reference statements)

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“…Similarly, higher ROSC rates before or at the ED also aligned with better survival. On visual inspection, provision of epinephrine and advanced airway and intravenous or intraosseous attempt do not align with survival 20 . Finally, post-resuscitation in-hospital care and course were not accounted for in this study and could impact outcomes 3,4 .…”

Section: Discussionmentioning

confidence: 98%

“…As noted, race/ethnicity or etiology of OHCA were not consistently available for analysis, but these types of data could be helpful to direct public health advocacy initiatives to prevent OHCA in children. Time to first epinephrine dose, a primary component of pediatric advanced life support, was associated with survival in a study of pediatric IHCA 20,21 . Interestingly, only 65% of children were given epinephrine by EMS in this study.…”

Section: Discussionmentioning

confidence: 99%

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Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America

et al. 2016

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Aim Outcomes for pediatric out-of-hospital cardiac arrest (OHCA) are poor. Our objective was to determine temporal trends in incidence and mortality for pediatric OHCA. Methods Adjusted incidence and hospital mortality rates of pediatric non-traumatic OHCA patients from 2007-2012 were analyzed using the 9 region Resuscitation Outcomes Consortium - Epidemiological Registry (ROC-Epistry) database. Children were divided into 4 age groups: perinatal (< 3 days), infants (3 days - 1 year), children (1 - 11 years), and adolescents (12 - 19 years). ROC regions were analyzed post-hoc. Results We studied 1,738 children with OHCA. The age- and sex-adjusted incidence rate of OHCA was 8.3 per 100,000 person-years (75.3 for infants vs. 3.7 for children and 6.3 for adolescents, per 100,000 person-years, p<0.001). Incidence rates differed by year (p<0.001) without overall linear trend. Annual survival rates ranged from 6.7-10.2%. Survival was highest in the perinatal (25%) and adolescent (17.3%) groups. Stratified by age group, survival rates over time were unchanged (all p>0.05) but there was a non-significant linear trend (1.3% increase) in infants. In the multivariable logistic regression analysis, infants, unwitnessed event, initial rhythm of asystole, and region were associated with worse survival, all p<0.001. Survival by region ranged from 2.6-14.7%. Regions with the highest survival had more cases of EMS-witnessed OHCA, bystander CPR, and increased EMS-defibrillation (all p<0.05). Conclusions Overall incidence and survival of children with OHCA in ROC regions did not significantly change over a recent 5 year period. Regional variation represents an opportunity for further study to improve outcomes.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America

et al. 2016

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“…2,3 However, delays in epinephrine administration are common, 4 and incremental delays in administration of epinephrine in non-shockable in-hospital cardiac arrests are associated with progressively worse survival. 4,5 Based on these studies, some have advocated for adopting time to epinephrine administration as a hospital quality-metric for in-hospital resuscitation care.…”

mentioning

confidence: 99%

Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest

et al. 2016

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Background For patients with in-hospital cardiac arrests due to non-shockable rhythms, delays in epinephrine administration beyond 5 minutes is associated with worse survival. However, the extent of hospital variation in delayed epinephrine administration and its impact on hospital-level outcomes is unknown. Methods Within Get with the Guidelines-Resuscitation, we identified 103,932 adult patients (≥18 years) at 548 hospitals with an in-hospital cardiac arrest due to a non-shockable rhythm who received at least 1 dose of epinephrine between 2000 to 2014. We constructed two-level hierarchical regression models to quantify hospital variation in rates of delayed epinephrine administration (>5 minutes) and its association with hospital rates of survival to discharge and survival with functional recovery. Results Overall, 13,213 (12.7%) patients had delays to epinephrine, and this rate varied markedly across hospitals (range: 0% to 53.8%). The odds of delay in epinephrine administration were 58% higher at one randomly selected hospital compared to a similar patient at another randomly selected hospitals (median odds ratio [OR] 1.58; 95% C.I. 1.51 – 1.64). Median risk-standardized survival rate was 12.0% (range: 5.4% to 31.9%) and risk-standardized survival with functional recovery was 7.4% (range: 0.9% to 30.8%). There was an inverse correlation between a hospital’s rate of delayed epinephrine administration and its risk-standardized rate of survival to discharge (ρ= −0.22, P<0.0001) and survival with functional recovery (ρ= −0.14, P=0.001). Compared to a median survival rate of 12.9% (interquartile range 11.1% to 15.4%) at hospitals in the lowest quartile of epinephrine delay, risk-standardized survival was 16% lower at hospitals in the quartile with the highest rate of epinephrine delays (10.8%, interquartile range: 9.7% to 12.7%). Conclusions Delays in epinephrine administration following in-hospital cardiac arrest are common and varies across hospitals. Hospitals with high rates of delayed epinephrine administration had lower rates of overall survival for in-hospital cardiac arrest due to non-shockable rhythm. Further studies are needed to determine if improving hospital performance on time to epinephrine administration, especially at hospitals with poor performance on this metric will lead to improved outcomes.

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“…7 In the rare instances when alarms truly represent impending cardiopulmonary arrest, delayed responses can have devastating patient outcomes. 8 This research priority should include developing guidelines describing how to best use continuous monitoring to optimize timely identification of deterioration while minimizing nonactionable alarms.…”

Section: Research Agendamentioning

confidence: 99%

Rapid Response Systems 20 Years Later

2016

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In 1990, Schein and colleagues changed the paradigm of in-hospital cardiopulmonary arrest. Their report, "Clinical Antecedents to In-Hospital Cardiopulmonary Arrest," provided evidence from adults suggesting that many arrests could have been prevented if existing signs of deterioration were identified, interpreted, communicated, and responded to appropriately. 1 Five years later, Liverpool Hospital published the first report of a rapid response system. 2 This marked the start of a patient safety movement that spread quickly to children's hospitals. 3 Rapid response systems aim to improve the detection and management of deterioration in hospitalized patients. They combine tools to help clinicians identify deterioration with medical emergency teams that can be summoned to the bedsides of ill patients. Rapid response system implementation was associated with reductions in cardiopulmonary arrests (relative risk 0.62, 95% confidence interval 0.46-0.84) and mortality (relative risk 0.79, 95% confidence interval 0.63-0.98) in a recent meta-analysis, 4 and reversed a trend of increasing critical deterioration events (a more proximate outcome) in a quasi-experimental study. 5 Due in part to mounting evidence, common sense appeal, and their inclusion in major initiatives like the Institute for Healthcare Improvement's 5 Million Lives Campaign, rapid response systems are now nearly universally present in hospitals worldwide.Unfortunately, rapid response systems have not fully solved the problem they targeted 20 years ago, and, despite progress, the challenges in pediatrics remain complex. Children still deteriorate on hospital wards, and 40% or more of these events may be preventable. 6 There is an opportunity to renew the enthusiasm that surrounded the first generation of rapid Conflict of Interest Disclosures: The authors report no additional potential conflicts of interest.

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Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest

Cited by 174 publications

References 42 publications

Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America

Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America

Hospital Variation in Time to Epinephrine for Nonshockable In-Hospital Cardiac Arrest

Rapid Response Systems 20 Years Later

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