OBJECTIVES:To determine the association between abnormal pupillary reactivity using automated infrared pupillometry and unfavorable outcome after pediatric cardiac arrest (CA). DESIGN:Single-center, retrospective, cohort study, 2018-2023. SETTING:Large tertiary PICU in the United States. PATIENTS:We identified 127 patients 18 years old or younger with 8464 pupillary assessments, greater than or equal to 2 measured within 72 hours after return of circulation (ROC). INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Abnormal pupillary reactivity was defined as greater than or equal to 2 neurological pupil index (NPi) values less than 3 in either eye. Unfavorable outcome was hospital discharge Pediatric Cerebral Performance Category of 4-6 and increase greater than or equal to 1 from pre-CA status. We explored the diagnostic performance of abnormal NPi for categorizing unfavorable outcome in the first 72 hours post-ROC, and at the time periods of 0-12, 12-24, 24-48, and 48-72 hours. We used a mixed-effects linear regression model to evaluate whether NPi values were associated with favorable vs. unfavorable outcome, after adjusting for clinical variables. Group-based trajectory modeling (GBTM) characterized NPi trajectories over time. Abnormal pupillary reactivity had a sensitivity of 66%, specificity 79%, positive predictive value of 82%, negative predictive value of 63%, and area under the receiver operating characteristic curve of 0.73 (95% CI, 0.65-0.80) for unfavorable outcome. Specificity did not differ between time periods. In the mixed-effects model, unfavorable outcome was associated with lower NPi values that decreased over time (interaction of time from ROC and outcome β = -0.02; p < 0.001). Through GBTM we identified a subgroup of patients with favorable outcome whose NPi was initially abnormal but subsequently improved over time. CONCLUSIONS:In our 2018-2023 experience, the presence of at least two NPi values less than 3 post-CA was associated with unfavorable outcome, with an acceptable level of diagnostic characterization. Of note, some patients with initially lower NPi values improved over time and had favorable outcome.

OBJECTIVES:To evaluate agency-level differences in determinations of futility (defined as withholding resuscitative efforts by emergency medical services [EMS]) and termination of resuscitation (TOR) during prehospital encounters for pediatric out-of-hospital cardiac arrest (OHCA). METHODS:We conducted a retrospective cross-sectional study of EMS activations for children (aged <18 years) with nontraumatic OHCA from the 2018-2023 National EMS Information System. Our outcomes of interest were futility and TOR. We constructed mixed-effects models including patient- and agency-level covariables. We quantified the magnitude of agency-level variation using the median odds ratio. RESULTS:We included 45 045 encounters treated by 6550 EMS agencies. Resuscitation was considered futile in 6.6%; among the remainder, TOR occurred in 25.4%. Futility determinations were less likely in witnessed arrests, events with bystander cardiopulmonary resuscitation (CPR), public locations, and respiratory/asphyxia or drowning etiologies and more likely in rural/wilderness settings and adolescents. TOR was less likely among witnessed arrests and noncardiac etiologies. The median odds ratio for a futility determination was 2.33 (95% CI 2.16-2.47), which exceeded in magnitude the odds ratio for all fixed-effect variables except for arrest witnessed status, etiology of drowning/submersion, bystander CPR status, tribal-type EMS agency, and wilderness events. The median odds ratio for TOR was 3.50 (95% CI 3.32-3.72), which exceeded all fixed-effect variables. CONCLUSIONS:We found substantial agency-level variation in determinations of futility and TOR for pediatric OHCA, underscoring that local EMS practice patterns may shape resuscitation decisions. These findings carry implications for patient care, resource utilization, and clinical outcomes.

Background Electroencephalography (EEG) is a critical tool for neuromonitoring and neuroprognostication in children with acute brain injury. Quantitative EEG (qEEG), particularly the alpha-delta ratio (ADR), can detect worsening cerebral ischemia in adults, but it is unknown whether it can identify more subtle and transient changes in cerebral blood flow, such as those induced by hypertonic saline (HTS), in children with acute brain injury. We aimed to determine whether we could identify a cohort of patients with an ADR response to HTS and to evaluate the association between an ADR response and neurologic outcomes in critically ill children with acute brain injury. Methods We conducted a retrospective cohort study of patients admitted to a pediatric intensive care unit with acute brain injury who received HTS during EEG monitoring from 2018 to 2023. The ADR was calculated before and after HTS administration. An ADR response was defined as a > 20% increase from baseline to within 30 min of receiving HTS in either hemisphere. The primary outcome was survival with favorable neurologic outcome, defined as a Functional Status Scale score change < 3 from prehospital baseline to discharge. Secondary outcome was survival to hospital discharge. Results Among 87 patients (median age 10 years [interquartile range 3.6-14.5], 46% female), 28% (24 of 87) had an ADR response to HTS. ADR responders were older (12.9 vs. 8.0 years; p = 0.004) and more likely to have continuous, normal-voltage EEG backgrounds (67% vs. 40%; p = 0.006). Patients with an ADR response had four times increased odds of favorable outcome and survival (odds ratio [OR] 4.0 [95% confidence interval (CI) 1.3-12.7] and OR 3.9 [95% CI 1.0-10.7], respectively). Conclusions An ADR increase > 20% following HTS was associated with increased odds of survival with favorable neurologic outcome and survival to hospital discharge in critically ill pediatric patients with acute brain injury. qEEG response to HTS may serve as a real-time, noninvasive biomarker of cerebral perfusion responsiveness.

OBJECTIVES:Linoleic acid (LA) is the most abundant polyunsaturated fatty acid in diet, and it is a precursor to inflammatory lipid mediators called oxylipins. The role of LA and its oxylipins in pediatric sepsis and organ injury is uncertain. Recently, pediatric sepsis phenotypes were described, with phenotype D characterized by the highest proportion of acute kidney injury (AKI), multiple organ failure, and risk of death. We aimed to test the hypothesis LA may play a role in sepsis-associated organ dysfunction. We therefore investigated whether increasing plasma LA and LA-derived lipoxygenase oxylipins are associated with sepsis phenotype D and with AKI in a cohort of critically ill children with sepsis. DESIGN:We studied a subset of 108 patients from the Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS) cohort by means of untargeted metabolomics of heparinized plasma samples. Primary outcome was phenotype group. Key secondary outcomes included AKI (defined as both creatinine > 1 mg/dL and oliguria < 0.5 mL/kg/hr), other organ dysfunctions, and hospital mortality. Patients were followed up until discharge or 28 days. SETTING:ICU. PATIENTS:One hundred eight patients with sepsis. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Higher LA levels were associated with sepsis phenotype D as compared with phenotypes A-C (odds ratio [OR], 1.67; 95% CI, 1.05-2.65; p = 0.03). LA-derived oxylipins 9-hydroxyoctadecadienoic acid and 13-hydroxyoctadecadienoic acid (9-HODE/13-HODE) were also associated with sepsis phenotype D (jointly reported in one variable; OR, 1.26; 95% CI, 1.01-1.57; p = 0.04). Higher LA showed a trend and 9-HODE/13-HODE was associated with AKI (OR, 1.52; 95% CI, 0.97-2.38; p = 0.07 and OR, 1.27; 95% CI, 1.03-1.56; p = 0.02, respectively). Neither LA nor oxylipins were associated with hospital mortality. CONCLUSIONS:LA levels and LA-derived lipoxygenase oxylipins are associated with pediatric sepsis phenotype D and AKI. These results support future mechanistic studies to investigate lipid metabolism in the pathophysiology of sepsis.

BACKGROUND:While longer duration of cardiopulmonary resuscitation (CPR) is associated with unfavorable patient outcomes after pediatric out-of-hospital cardiac arrest (OHCA), it remains unclear how the probability of survival changes as a function of CPR duration. METHODS:We conducted a retrospective cohort study of the Resuscitation Outcomes Consortium Epidemiologic Registry, including consecutive patients with non-traumatic OHCA at ten regional coordinating sites in the US and Canada from 2011 to 2015. We included pediatric patients (age <18 years) with emergency medical services (EMS)-treated OHCA. The exposure was EMS-initiated prehospital CPR duration in minutes, defined as the interval between the start of chest compressions by EMS clinicians and prehospital return of spontaneous circulation (ROSC), prehospital termination of resuscitation (TOR), or hospital arrival. The outcome was survival to hospital discharge. Time-dependent probability of subsequently surviving to hospital discharge if patients with ongoing CPR at each minute received further CPR beyond that time point was estimated, assuming that all decisions on TOR prior to or at that time point were adequate. RESULTS:Among 1313 included patients (median [IQR] age, 1[0-9]), 236 (18.0%) achieved prehospital ROSC with a median CPR duration of 10 min (IQR 5.5-16.5 min); 1077 did not; and 136 (10.4%) survived to hospital discharge. The time-dependent probabilities of survival to hospital discharge for patients with ongoing CPR were 7.9% (95% CI: 6.4-9.3%) at 1 min and decreased to less than 1% at 14.8 min (95% CI: 11.1-22.0 min) of EMS-initiated prehospital CPR duration. The upper bound of 95% CI of the probabilities of survival decreased to less than 1% (0.86%, 95% CI: 0.34-0.94%) at 22.0 min. CONCLUSION:In this North American retrospective cohort study of pediatric patients with OHCA, we quantified the time-dependent probability of survival to hospital discharge as a function of prehospital CPR duration. The findings provide EMS clinicians and patients' surrogates with objective insights into the likelihood of survival when CPR is continued beyond 15 min.

OBJECTIVES:Pediatric resuscitation guidelines support using diastolic blood pressure (DBP) as a marker of cardiopulmonary resuscitation (CPR) quality. Thresholds of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children were derived from data limited to the first 10 minutes of CPR, regardless of event duration. We aimed to describe DBP trajectories throughout in-hospital cardiac arrest and evaluate associations between DBP thresholds and return of spontaneous circulation (ROSC) in prolonged CPR (≥ 10 min). DESIGN:Single-center retrospective cohort study (2017-2023). SETTING:PICU and CICU. PATIENTS:Pediatric IHCA with invasive arterial BP monitoring. SETTING AND PATIENTS:Pediatric IHCAs with invasive arterial BP monitoring. INTERVENTIONS:None. MEASUREMENT AND MAIN RESULTS:Events with greater than or equal to 1 minute of evaluable DBP data were included in trend analyses; those with greater than or equal to 1 minute of evaluable DBP data after 10 minutes of CPR were included in prolonged CPR analyses. Linear and mixed-effects regression assessed DBP trends; univariate logistic regression evaluated associations between DBP thresholds and ROSC. Among 118 events (median age 0.4 yr; 69% with congenital heart disease), DBP rose early and plateaued above guideline thresholds. Early ROSC was associated with higher average DBP ( p = 0.02) and steeper early DBP rise ( p < 0.001). In 46 prolonged events, 80% had mean DBP above guideline thresholds. In prolonged CPR, an upward DBP trend was associated with ROSC ( p < 0.001). In prolonged CPR, meeting current DBP thresholds was not significantly associated with ROSC, but achieving higher thresholds (≥ 30 mm Hg in infants and ≥ 35 mm Hg in children) later in CPR was associated with ROSC (odds ratio 7.14; 95% CI, 1.58-51.35; p = 0.009). CONCLUSIONS:DBP can be sustained above current thresholds during prolonged CPR. Larger cohort studies are needed to determine if higher, patient-specific, and time-dependent DBP targets are required to achieve ROSC in prolonged CPR.

OBJECTIVES:While advanced airway management (AAM) is commonly performed for children with out-of-hospital cardiac arrest (OHCA), the benefit and optimal timing of AAM remains unclear. To determine whether earlier prehospital AAM is associated with patient outcomes compared with later or no AAM in children with OHCA. METHODS:Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services (EMS), using the Resuscitation Outcomes Consortium Epidemiologic Registry-Cardiac Arrest at 10 sites in the United States and Canada from April 2011 to June 2015. The exposures are early prehospital AAM (defined as successful AAM within 10 minutes of EMS arrival) and any successful prehospital AAM (endotracheal intubation or supraglottic airway placement). The primary outcome was survival to hospital discharge. Children who received successful prehospital AAM at each minute after EMS arrival were matched, using time-dependent propensity scores, to children at risk of AAM in the same minute. RESULTS:Among 954 eligible pediatric patients (median [IQR] age, 1 [0 to 11] years), 521 (54.6%) received prehospital AAM, and 433 (45.4%) did not. Overall, 91 (9.5%) survived to discharge. In the propensity score-matched cohort (922 matched cases), successful AAM ≤10 minutes was associated with higher likelihood of survival to hospital discharge (risk ratio [RR], 1.93; 95% CI, 1.01-3.70) compared with children at risk of receiving AAM. In contrast, when successful prehospital AAM was considered regardless of timing, any successful AAM was not associated with survival (RR, 1.35; 95% CI, 0.75-2.43). CONCLUSIONS:In this North American cohort of pediatric OHCA, earlier AAM (successful AAM within 10 minutes) was associated with survival to hospital discharge. However, successful prehospital AAM at any time was not associated with survival to hospital discharge. These findings suggest that performing AAM earlier in the resuscitation may have a potential benefit for children with OHCA.

AIMS:Heart rate variability (HRV), a non-invasive measure of autonomic function, may offer prognostic value after pediatric cardiac arrest. We used machine learning models to determine whether HRV features within the first 24 h after return of spontaneous circulation can predict outcomes in children following cardiac arrest, and whether adding clinical cardiac arrest characteristics improves model performance. METHODS:Retrospective study of children who received post-arrest care in the PICU at the Children's Hospital of Philadelphia from 2020 to 2023. Thirty-six HRV features were extracted from ECG recordings and Extreme Gradient Boosting (XGB) models were trained to predict unfavorable neurological outcome, defined as Pediatric Cerebral Performance Category 4-6 and an increase >1 from baseline. Models were evaluated by cross-validation across the entire 24-h period and within sequential 6-h epochs. Additional models included clinical arrest characteristics. Performance was assessed by area under the receiver operating characteristic curve (AUROC). RESULTS:Of the 75 patients who met inclusion criteria (median age 6.8 [IQR 10.4] years), 51% had an unfavorable outcome. Model considering HRV features and age achieved an AUROC of 0.80 (95% CI: 0.68-0.88). Top HRV predictors included standard deviation (SDNN), power at very low and low frequency bands, entropy, and fractal scaling. Performance was similar across the 6-h epochs (p's > 0.1). Adding cardiac arrest characteristics did not improve model performance (AUROC 0.83 [0.73-0.92], p > 0.41). CONCLUSION:Using machine learning, HRV features within 24 h after pediatric cardiac arrest predict unfavorable outcome with AUROC 0.8. Adding clinical variables did not improve model performance.

BACKGROUND:The optimal sequence of epinephrine administration and advanced airway management (AAM) successfully delivered during pediatric out-of-hospital cardiac arrest (OHCA) is unclear. Our objective was to determine whether the sequence of first successful epinephrine administration and first successful AAM is associated with survival and functional outcomes in pediatric OHCA. METHODS:We performed a secondary analysis of the Resuscitation Outcomes Consortium Epidemiologic Registry-Cardiac Arrest, a prospective database from 10 US and Canadian regions (2011-2015). We included children (age < 18 years) with non-traumatic OHCA who received epinephrine and/or AAM (endotracheal intubation or supraglottic airway). Our exposure was the sequence of first successful epinephrine administration versus first successful AAM (epinephrine-first or AAM-first). The primary outcome was survival at hospital discharge. Secondary outcomes were a favorable functional outcome at discharge (modified Rankin Scale ≤ 3) and return of spontaneous circulation (ROSC) at hospital arrival. We adjusted for group differences using inverse-probability-of-treatment weighting derived from a propensity score and compared outcomes with logistic regression. RESULTS:Of 886 eligible patients, 297 (33.5%) received AAM as the first successful intervention, 558 (63.0%) received epinephrine as the first successful intervention, and 31 (3.5%) received these at the same recorded second. There was no significant difference in survival at discharge between the epinephrine-first and AAM-first groups (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.69-1.52). Relative to the AAM-first group, the epinephrine-first group was associated with higher odds of ROSC at hospital arrival (OR, 1.38; 95% CI, 1.06-1.80) but lower odds of favorable functional outcome at hospital discharge (OR, 0.32; 95% CI, 0.13-0.76). CONCLUSIONS:In this large observational study of pediatric OHCA, the observed sequence of first successful epinephrine administration and first successful AAM was not associated with survival to hospital discharge.

In this article, we describe the potential for personalized cardiopulmonary resuscitation using physiology to guide drug administration. We also highlight the limitations of the current evidence to inform a more individualized approach. Several areas for possible modifications to drug management are ripe for investigation, including: vasopressor selection and titration based on diastolic blood pressure responses; special physiologic circumstances in which sodium bicarbonate or calcium may be beneficial; and certain electrophysiologic states in shockable cardiac arrest, which may favor lidocaine or amiodarone.

Importance:Lower survival rates among Black adults relative to White adults after in-hospital cardiac arrest are well-described, but these findings have not been consistently replicated in pediatric studies. Objective:To use a large, national, population-based inpatient database to evaluate the associations between in-hospital mortality in children receiving cardiopulmonary resuscitation (CPR) and patient race or ethnicity, patient insurance status, and the treating hospital's proportion of Black and publicly insured patients. Design, Setting, and Participants:This retrospective population-based cohort study used the Healthcare Cost and Utilization Project Kids' Inpatient Database (1997-2019 triennial versions). Participants included pediatric inpatients (aged <18 years) who received in-hospital CPR. Initial data analysis occurred January 20 to July 31, 2023. Revision analyses were completed December 1, 2024, to March 3, 2025. Exposures:The exposures for the primary analyses were race or ethnicity and insurance payer. The secondary analyses exposures were the proportion of the treating hospital's admissions (not limited to those receiving CPR) of Black patients and of publicly insured patients. Main Outcomes and Measures:The primary outcome for all analyses was in-hospital mortality. Results:The final cohort included 27 332 children (6366 neonates aged 5-28 days [23.3%], 9665 infants aged 29 days to <1 year [35.4%], 4867 aged 1 year to <8 years [17.8%], and 6434 aged ≥8 years [23.5%]; 15 356 male [56.2%]; 6081 (22.2%) Black; 5123 (18.7%) Hispanic; 13 062 (47.8%) White; and 3066 (11.2%) other race or ethnicity) who received in-hospital CPR at sites with 3899 unique hospital identification numbers. Relative to White children, higher odds of in-hospital mortality were observed for Black (adjusted odds ratio [AOR], 1.20; 95% CI, 1.08-1.34; P < .001) and Hispanic (AOR, 1.16; 95% CI, 1.04-1.30; P = .006) children and those of other race or ethnicity (AOR, 1.37; 95% CI 1.20-1.58; P < .001). Public insurance was not associated with in-hospital mortality compared with private insurance (AOR, 1.00; 95% CI, 0.91-1.11; P = .93). On multivariable analysis of the 2003-2019 datasets, children receiving CPR at hospitals with the highest proportion of Black patients (>30.1%) had higher odds of in-hospital mortality than children receiving CPR at hospitals with the lowest proportion of Black patients (AOR, 1.50; 95% CI, 1.17-1.92; P = .001). Conclusions and Relevance:In this retrospective cohort study of pediatric in-hospital cardiac arrest in a large, national, administrative dataset, children of racial and ethnic minority groups receiving CPR had higher odds of in-hospital mortality. In addition, the odds of in-hospital mortality among children receiving CPR were higher at hospitals with the highest proportion of Black patients.

Importance:The optimal airway management during pediatric in-hospital cardiac arrest (IHCA) is unknown. Objective:To evaluate intubation trends during pediatric IHCA between 2000 and 2022, and determine the association of intra-arrest intubation with survival in a recent cohort of patients (2017-2022). Design, Setting, and Participants:This retrospective cohort study (analysis performed between June 2023 and October 2024) used data from the multicenter American Heart Association Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with IHCA from 2000 through 2022 were included. Exposure:Intra-arrest endotracheal intubation. Main Outcomes and Measures:The primary outcome was survival to hospital discharge. Intra-arrest intubation trends were assessed using nonparametric test for trend. A time-dependent propensity matched analysis assessed the association between intra-arrest intubation and hospital survival from 2017 through 2022. Each minute, patients intubated were matched with patients at risk of intubation using a propensity score, with forced matching on stratification variables and replacement of controls. Mixed-effects logistic regression assessed the association with survival outcomes, with subgroup analysis by age and illness category. Results:The cohort included 3262 pediatric patients with IHCA (median age, 12.0 [IQR, 3.0-83.8] months; 1775 [54.4%] male) with no advanced airway at CPR onset. Return of spontaneous circulation was attained in 2413 patients (74.0%), and 1748 (53.6%) survived to hospital discharge. The intubation rate decreased over time (33 of 39 [84.6%] in 2000 to 112 of 168 [66.7%] in 2022; P < .001). In the 2017-2022 cohort, intubation vs nonintubation in each minute of CPR was associated with decreased discharge survival odds in unadjusted analysis (odds ratio [OR], 0.18; 95% CI, 0.14-0.24; P < .001) but not after matching (adjusted OR, 1.18; 95% CI, 0.90-1.53; P = .23). In children aged 8 years or older, after matching, intubation compared with nonintubation in each minute was associated with increased odds of discharge survival (adjusted OR, 1.91; 95% CI, 1.09-3.33; P = .02). Conclusions and Relevance:In this cohort study of pediatric patients with IHCA between 2017 and 2022 without an advanced airway at the start of CPR, no association was identified between intra-arrest tracheal intubation and hospital survival after time-dependent propensity score matching. In subgroup analysis, intra-arrest intubation in children 8 years or older was associated with higher survival odds. These findings may have important clinical implications for clinicians caring for children with IHCA and warrant further investigation into the physiologic and practical mechanisms of this association.

BACKGROUND AND OBJECTIVES:Cerebrovascular pressure autoregulation (CAR) maintains adequate cerebral blood flow (CBF) despite changes in cerebral perfusion pressure. CAR is disrupted after cardiac arrest, making the brain vulnerable to inadequate perfusion and oxygen delivery at population-derived guideline-recommended blood pressures. A metric of CAR can be used to determine the mean arterial pressure (MAP) at which CAR is most preserved, termed the optimal MAP (MAPopt). Our objective was to determine whether deviations above or below personalized CAR-derived MAPopt after pediatric cardiac arrest are associated with outcomes. METHODS:We conducted a retrospective analysis of prospectively collected data of patients aged 18 years or younger admitted to the pediatric intensive care unit at Children's Hospital of Philadelphia between October 2018 and December 2023 for post-cardiac arrest care. We computed cerebral oximetry index (COx), a metric of CAR, using a moving, linear correlation between time-synchronized brain tissue oxygenation (StO2) from near-infrared spectroscopy and MAP. A multiwindow weighted algorithm determined each patient's MAPopt over time. We compared each patient's MAP with their CAR-derived MAPopt during the first 72 hours after arrest. Unfavorable outcome was defined as a Pediatric Cerebral Performance Category score of 4-6 at hospital discharge with change of ≥1 from baseline. We tested association between burden (combining magnitude and duration) of MAP < MAPopt-5 mm Hg and unfavorable outcome, and between duration of MAP > MAPopt and favorable outcomes using logistic regression models adjusted for age, prearrest developmental disability, and measures of arrest severity. RESULTS:Among 147 patients included (median age 4.5 years, interquartile range [IQR] 1.1-11.7 years, 59% male), 52% had unfavorable outcomes. The median time from return of circulation to data collection was 4 (IQR 2.1-8.3) hours. The median burden of MAP < MAPopt-5 mm Hg was greater for the unfavorable outcome group compared with the favorable outcome group (192 [IQR 114-310] vs 147 [IQR 86-199] mm Hg·min/h, p = 0.002). A 1 SD higher burden of MAP < MAPopt-5 was associated with 2.4 times increased odds of unfavorable outcomes (95% CI 1.24-4.51). Patients with favorable outcomes had a longer duration of MAP > MAPopt than patients with unfavorable outcomes (48% [IQR 38-56] vs 40% [IQR 28-52], p = 0.011). One SD higher duration of MAP > MAPopt was associated with 2.5 times increased odds of favorable outcomes (95% CI 1.20-5.13). DISCUSSION:Greater burden of MAP < MAPopt-5 mm Hg in the first 72 hours after pediatric cardiac arrest was associated with increased odds of unfavorable outcomes after controlling for potential confounders, and longer duration of MAP > MAPopt was associated with increased odds of favorable outcomes.

IMPORTANCE:Right atrial (RA) dysfunction is associated with worse outcomes in some populations with pulmonary hypertension or respiratory failure but the prevalence and correlates of RA dysfunction in pediatric acute respiratory distress syndrome (PARDS) are unknown. OBJECTIVES:The aim of this study was to evaluate RA function by characterizing the prevalence and pattern of RA dysfunction within the first 24 hours of PARDS onset. We hypothesized that RA dysfunction would be common and correlate with the presence of pulmonary hypertension and right ventricular (RV) systolic dysfunction. DESIGN, SETTING, AND PARTICIPANTS:Retrospective, single-center cohort study at a tertiary care PICU of children (< 18 yr) with a clinically obtained echocardiogram within 24 hours following PARDS diagnosis and healthy controls without cardiopulmonary disease. MAIN OUTCOMES AND MEASURES:Echocardiograms were evaluated for conventional and speckle-tracking (or strain) echocardiographic measures of RA and RV systolic function. Nonparametric summary statistics, comparisons, and correlational analyses were completed. RESULTS:Ninety-two PARDS patients and 55 controls were included. Using a priori thresholds (> 2 sds of control values), 49% (n = 45) of PARDS patients demonstrated RA dysfunction in at least one RA functional metric. The maximal RA strain during the reservoir phase was reduced in PARDS compared with controls (median 40.2% vs. 53.7%; p < 0.001). Patients with echocardiographic evidence of pulmonary hypertension had lower maximal RA strain during the reservoir phase (31.7%) compared with patients without (40.5%; p < 0.05). Patients with higher brain-type natriuretic peptide plasma concentrations had worse RA function. RA function significantly correlated with conventional and strain measures of RV systolic function. CONCLUSIONS AND RELEVANCE:RA dysfunction is common within the first 24 hours of PARDS onset. RA dysfunction during the reservoir phase is associated with pulmonary hypertension and RV systolic dysfunction. Future studies investigating trajectories of RA function and their association with outcomes in PARDS patients are needed.

Rationale: Delayed (>5 minutes) epinephrine during pediatric in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Epinephrine is nearly always given earlier, limiting 5 minutes as a quality target. Objectives: To assess early epinephrine administration (⩽2 minutes) on outcomes and hemodynamics during cardiopulmonary resuscitation (CPR) in pediatric IHCA from pulseless, nonshockable rhythms. Methods: This study leveraged the database of the ICU-RESUS (Intensive Care Unit Resuscitation) project (clinicaltrials.gov identifier NCT02837497). Primary exposure was the time to epinephrine bolus: early versus >2 minutes. Primary outcome was survival to discharge. Secondary outcomes included the return of spontaneous circulation (ROSC), survival with favorable neurologic outcome, change from baseline to discharge Functional Status Scale (FSS) score, total FSS score at discharge, new morbidity among survivors, and invasively measured blood pressure during the first 10 minutes of CPR. Results: Among 352 CPR events, median age was 1.0 (interquartile range [IQR], 0.3-8.0) year, 186 (53%) were male, and 185 (52.6%) had cardiac disease. Early epinephrine was administered in 273 (78%), and median time to administration was 1.0 (0.0-2.0) minute. Survival to discharge was similar between patients who received early epinephrine and those who did not. Early epinephrine administration was associated with higher ROSC, a change from baseline to discharge in FSS, lower total FSS scores at discharge, and lower rates of new morbidity compared with epinephrine administration at >2 minutes. The probability of ROSC and survival to discharge with favorable neurologic outcome decreased for each minute of delay in epinephrine administration. There was no difference in the invasive blood pressure targets during the first 10 minutes of CPR. Conclusions: Early epinephrine administration was common and was associated with higher ROSC and improved functional outcomes compared with epinephrine administration at >2 minutes in pediatric IHCA.