Abstract Background Rigorous development and evaluation of implementation outcome measures is needed to advance the field of implementation science. The Acceptability of Intervention Measure (AIM), Feasibility of Intervention Measure (FIM), and the Intervention Appropriateness Measure (IAM) are commonly used, psychometrically validated measures. The objective of the current analysis was to analyze use of the AIM, FIM, and IAM in a single-center pediatric intensive care (PICU) unit study. Methods This was a secondary analysis of a mixed-methods interventional study. The initial project studied development of a novel cardiac arrest ventilation rate metronome to improve adherence to guideline-recommended ventilation rates during CPR; study components included contextual inquiry, participatory intervention design, and simulation usability testing. Using a purposive sampling strategy for pre-implementation contextual inquiry, eligible participants included multidisciplinary PICU clinicians. The pre-implementation questionnaire asked about current cardiac arrest ventilation practices and perceived acceptability, appropriateness, and feasibility of our proposed intervention (AIM, FIM, and IAM). Five-point scale Likert data were summarized using descriptive statistics (medians and interquartile ranges). A score of > 3 was considered favorable. Results Of 133 started instances of the pre-implementation survey, 107 were completed (80.5%). The response rate was 30.6% (107/350). Respondents included 34 nurses (31.8%), 18 respiratory therapists (16.8%), and 55 ordering providers (physicians and nurse practitioners; 51.4%). Most respondents (79/107; 73.8%) had previously participated in > 10 PICU cardiac arrests. Appropriateness, acceptability, and feasibility of the ventilation metronome were favorable (appropriateness median: 4 [IQR 4,5]; acceptability median: 4 [IQR 3,5]; feasibility median: 4 [IQR 4,4.5]). For each AIM, IAM, and FIM statement, ≥24.3% of all responses were the highest value on the 5-point scale. Of the 19.5% of survey instances with only partial responses, all but one (26/27; 96.3%) were stopped at the AIM, IAM, FIM matrix of statements. Conclusions In this single-center PICU study utilizing the previously validated Acceptability of Intervention Measure, Feasibility of Intervention Measure, and Intervention Appropriateness Measure, there were several challenges associated with the use of these scales, including (1) survey responses that were terminated at the portion of the questionnaire presenting the AIM, IAM, and FIM and (2) ceiling effect.

OBJECTIVE:To assess the evidence on volume-controlled mechanical ventilation versus manual ventilation or other ventilation modes during cardiopulmonary resuscitation (CPR). METHODS:On 18 March 2026, we searched PubMed, Embase, and Web of Science (PROSPERO: CRD420251110999). Randomized trials and non-randomized studies in children or adults with cardiac arrest and an advanced airway were included. Risk of bias was assessed using RoB2 and ROBINS-I tools. Meta-analyses were performed when appropriate, and certainty of evidence was assessed using GRADE. RESULTS:We screened 12,004 abstracts and included 13 articles consisting of six trials enrolling 461 patients and seven non-randomized studies including 4607 patients. No study reported data on children. Meta-analysis of 120 patients from two randomized trials comparing volume-controlled to manual ventilation showed no difference for return of spontaneous circulation (ROSC) (odds ratio, 1.31; 95%-confidence interval, 0.64-2.71). Comparisons to pressure-controlled and CPR-specific modes were limited to a single trial each, with uncertain results. Randomized trials were at low to high risk of bias. Non-randomized studies were at serious or critical risk of bias. The certainty of evidence was very low to low across comparisons. CONCLUSION:Very low to low certainty evidence from randomized trials suggests no significant difference in clinical outcomes between volume-controlled mechanical ventilation and manual ventilation. The relative effectiveness of volume-controlled ventilation compared to other mechanical ventilation modes is uncertain.

OBJECTIVE:Pediatric emergency transfers (ETs), unplanned intensive care unit (ICU) transfers in which a child needs intubation, vasopressor initiation, or at least 60 mL/kg fluid resuscitation within 1 hour, are associated with longer stays and higher mortality, yet their financial burden is unknown. Thus, we compared post-transfer financial charges for ETs vs non-ETs. PATIENTS AND METHODS:We conducted a retrospective cohort study of 2034 ICU transfers between 2015 and 2019 at a freestanding children's hospital. We compared charges between ETs and non-ETs, including aggregate post-transfer ICU charges (transfer through ICU discharge), aggregate total post-transfer hospital charges (transfer through 100 days post-transfer), and average daily post-transfer charges over the first 100 days. Charge comparisons were adjusted for age, presence of complex chronic conditions, pretransfer length of stay, originating service, and deterioration type using regression models with generalized estimating equations. RESULTS:Compared to non-ETs, ETs had higher unadjusted post-transfer charges (ICU: 108% [95% CI 51-188], P < .01; total: 91% [95% CI 50-143], P < .01; daily: 61% [95% CI 35-91], P < .01). After adjustment, ETs remained associated with higher post-transfer charges (ICU: 65% [95% CI 22-123], P < .01); total: 49% [95% CI 17-90], P < .01; daily: 20% [95% CI 3-98], P = .02). ET-associated post-transfer charge increases varied significantly by originating service (general pediatrics: 104% [95% CI 30-221] vs surgical services: -19% [95% CI -55 to 47], P < .01) and deterioration type (respiratory: 177% [52%-407%] vs circulatory: 2% [-28% to 47%], P < .01). CONCLUSIONS:ETs are associated with significantly higher post-transfer charges for hospitalized children. This financial impact highlights the economic imperative, alongside clinical benefits, for investing in systems aimed at preventing delayed escalation and reducing ETs.

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:To characterize the quality of bag-mask ventilation (BMV) before tracheal intubation in children in the PICU and to evaluate the association between poor BMV quality and adverse airway outcomes. DESIGN:Single-center, pilot observational study, 2019-2022. SETTING:Large, urban quaternary care PICU. PATIENTS:Pediatric patients requiring BMV before tracheal intubation. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Using a respiratory function monitor, we collected flow and pressure data from 8446 BMV breaths before tracheal intubation in 85 children in the PICU (median age, 3.3 yr [interquartile range, 1.4-8.3 yr]). Adverse airway outcomes (i.e., tracheal intubation-associated event and/or pulse oximetry desaturation < 80%) occurred in 14 of 85 patients (16.5%). Low-quality BMV breaths were defined as: 1) inadequate or excessive exhaled tidal volume (VTe < 4 or > 12 mL/kg); 2) excessive peak inspiratory pressure (PIP) and excessive VTe; 3) excessive facemask leak (> 40%); or 4) failure to relieve upper airway obstruction. Overall, 78.0% of BMV breaths met at least one low-quality criterion; most frequently inadequate or excessive VTe (55.5%), followed by excessive leak (46.2%). Infants (< 1 yr) and young children (1-7 yr), compared with older children (8-17 yr), had a higher proportion of low-quality BMV breaths overall (86.0%, 85.5% vs. 57.9%; p < 0.001 for both), with inadequate or excessive VTe (57.7%, 61.1% vs. 43.7%; p < 0.001 for both), excessive leak (50.6%, 49.2% vs. 37.0%; p < 0.001 for both), and excessive PIP with excessive VTe (17.5%, 19.4% vs. 6.4%; p < 0.001). After controlling for respiratory pathology, low-quality BMV was associated with 2.8-times greater odds of adverse airway outcome (adjusted odds ratio, 2.8 [95% CI, 1.2-6.2]; p = 0.01). CONCLUSIONS:The majority of BMV breaths delivered to children before tracheal intubation in the PICU were of low-quality. And, such breaths, were more frequent in younger children and were associated with greater odds of adverse airway outcomes.

BACKGROUND:. Existing PICU early warning systems lack sufficient accuracy and timeliness for effective preparation. Machine learning approaches may improve prediction of critical deterioration events (CDEs), but their operational utility relative to existing tools remains unclear. OBJECTIVES:. To develop a machine learning model for early detection of CDEs and evaluate operational utility against existing tools using a novel alert burden analysis. DERIVATION COHORT:. PICU admissions (ages 0–24 yr, stay ≥ 24 hr) at a quaternary children’s hospital from 2014 to 2020 (n = 12,771 patients; 21,141 admissions). CDEs (6% of patients) included cardiopulmonary resuscitation, extracorporeal membrane oxygenation initiation, dilute epinephrine administration, or unplanned intubation. VALIDATION COHORT:. Temporally distinct PICU admissions from 2021 to 2022 (n = 5144 patients; 6929 admissions; 6% CDE rate). PREDICTION MODEL:. An ensemble of extreme gradient-boosted models (PICU Warning INdex [P-WIN]) trained to predict CDEs at 1–12-hour horizons using 550 features derived from demographics, medications, laboratory results, and vital signs. RESULTS:. P-WIN demonstrated excellent discrimination at 2-hour (area under the receiver operating characteristic curve [AUROC], 0.95 [95% CI, 0.94–0.96] and area under the precision-recall curve [AUPRC], 0.76 [95% CI, 0.72–0.80]) and 12-hour horizons (AUROC, 0.93 [95% CI, 0.92–0.94] and AUPRC, 0.68 [95% CI, 0.64–0.72]). To alert before 80% of events, P-WIN generated 0.20 alerts per patient-day at a median 10.17 hours before CDE. Compared with the existing rule-based PICU Warning Tool (alerting before 38% of events), P-WIN generated one-third the alert burden at equivalent sensitivity (0.03 vs. 0.10 alerts per patient-day). CONCLUSIONS:. P-WIN accurately predicted PICU CDEs up to 12 hours in advance with low alert burden, providing a viable opportunity for shifting care from reactive rescue to proactive, resource-intensive preparation and prevention.

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:Resveratrol (RES), a common type of plant polyphenols, has demonstrated promising therapeutic efficacy and safety in animal models of pancreatitis and pancreatic cancer. However, a comprehensive analysis of these data is currently unavailable. This study aimed to systematically review the preclinical evidence regarding RES's effects on animal models of pancreatitis and pancreatic cancer via meta-analyses and optimised machine learning techniques. METHODS:Animal studies published from inception until June 30th 2024, were systematically retrieved and manually filtrated across databases including PubMed, EMBASE, Web of Science, Ovid MEDLINE, Scopus, and Cochrane Library. Methodological quality of the included studies was evaluated following the SYRCLE's RoB tool. Predefined outcomes included histopathology and relevant biochemical parameters for acute pancreatitis, and tumour weight/tumour volume for pancreatic cancer, comparing treatment and model groups. Pooled effect sizes of the outcomes were calculated using STATA 17.0 software. Machine learning techniques were employed to predict the optimal usage and dosage of RES in pancreatitis models. RESULTS:A total of 50 studies comprising 33 for acute pancreatitis, 1 chronic pancreatitis, and 16 for pancreatic cancer were included for data synthesis after screening 996 records. RES demonstrated significant improvements on pancreatic histopathology score, pancreatic function parameters (serum amylase and lipase), inflammatory markers (TNF-α, IL-1β, IL-6, and pancreatic myeloperoxidase), oxidative biomarkers (malondialdehyde and superoxide dismutase), and lung injury (lung histopathology and myeloperoxidase) in acute pancreatitis models. In pancreatic cancer models, RES notably reduced tumour weight and volume. Machine learning highlighted tree-structured Parzen estimator-optimised gradient boosted decision tree model as achieving the best performance, identifying course after disease induction, total dosage, single dosage, and total number of doses as critical factors for improving pancreatic histology. Optimal single dosage was 20-105 mg/kg with 3 to 9 doses. CONCLUSION:This study comprehensively demonstrates the therapeutic effects of RES in mitigating pancreatitis and pancreatic cancer in animal models. Anti-inflammatory, anti-oxidative, and anti-tumour growth properties are potential mechanisms of action for RES.

AIMS:To characterize and compare modes of death and reasons for withdrawal of life-sustaining therapies (WLST) in children admitted to an intensive care unit (ICU) after in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). METHODS:Single center retrospective study of children who experienced IHCA or OHCA, were admitted to an ICU from January 2017 to March 2023, and died prior to discharge. Modes of death were classified as: a) death by neurologic criteria (DNC), b) WLST, c) recurrent arrest with attempted resuscitation ("recurrent arrest") or d) recurrent arrest without attempted resuscitation ("recurrent arrest/DNAR"). RESULTS:Of 746 patients receiving post-arrest care, 260 non-survivors were analyzed. Of 155 IHCA patients, mode of death was DNC 8 (5%), WLST 87 (56%), recurrent arrest 33 (21%), recurrent arrest/DNAR 27 (18%). The primary reason for WLST was poor cardiovascular prognosis (WLST-CV) (40/87 [46%]). Of 105 OHCA patients, mode of death was DNC 51 (49%), WLST 38 (36%), recurrent arrest 8 (7.5%), recurrent arrest/DNAR 8 (7.5%). The primary reason for WLST was poor neurologic prognosis (WLST-N) (32/38 [84%]). Compared to OHCA patients, children with IHCA were less likely to die from DNC (p < 0.001) and more often underwent WLST-CV (p < 0.001). The median time to death was longer for IHCA vs. OHCA (5 [0.8,30] vs 3 [1.5,6] days, p = 0.03). CONCLUSIONS:Following an IHCA, non-survivors more frequently died from circulatory failure, including WLST-CV or recurrent arrest, while OHCA non-survivors more frequently died from neurologic injury, including DNC and WLST-N. Children who had an IHCA died later after their arrest than those who had an OHCA.

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.

OBJECTIVE:To describe the association between severe intracranial hemorrhage or ischemia following pediatric in-hospital cardiac arrest (IHCA) and clinical outcomes. DESIGN:Retrospective cohort study. SETTING:ICUs that participated in the ICU-RESUS (NCT02837497) trial. PATIENTS:Children enrolled in ICU-RESUS with return of circulation following IHCA who had a head computerized tomography (CT) within 7 days of cardiac arrest. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Radiology reports from CT scans post-IHCA were categorized for the presence ischemia and hemorrhage. The primary exposure was severe intracranial hemorrhage or ischemia, and the primary outcome was unfavorable neurologic outcome (defined as death or change in Pediatric Cerebral Performance Category ≥1 from baseline resulting in hospital discharge PCPC 4-5). Of the 1000 patients in ICU-RESUS with return of circulation, 180 had a CT, and 73 (40.5 %) had severe hemorrhage or ischemia. Patients with severe hemorrhage or ischemia had longer duration of CPR (33 [8-50] vs 12 [5-31] minutes, p < 0.001), more epinephrine doses (5 [2-14.5 vs 3 [2-8.5], p = 0.031), more often received eCPR (59 % vs 39 %, p = 0.010), had higher post-arrest lactate levels (mmol/L) (14.1 [9.3-19.6] vs 10.5 [6.3-15.3], p = 0.018) and lower post-arrest pH (7.1 [7-7.3] vs 7.2 [7.1-7.3), p = 0.003) than patients without severe hemorrhage or ischemia. Severe hemorrhage or severe ischemia was more common among patients with unfavorable compared to favorable outcome (56 % vs 21 %, p < 0.001). All 7 patients with severe hemorrhage and ischemia died. CONCLUSIONS:The presence of severe intracranial hemorrhage or ischemia on head CT within the first 7 days post-IHCA was associated with unfavorable outcomes, and all patients with both died. However, severe hemorrhage or ischemia post-IHCA is not always a poor prognostic feature, as some patients do survive with favorable neurologic outcome. Neuroimaging findings should be taken in context with the rest of a patient's clinical course and not in isolation.

OBJECTIVES:Prearrest sepsis has been associated with particularly poor outcomes among children who suffer in-hospital cardiac arrest (IHCA), but there is a paucity of dedicated studies on the topic. In this study of children receiving cardiopulmonary resuscitation (CPR) in the ICU, our objective was to determine the associations of sepsis with IHCA outcomes and intraarrest physiology. DESIGN:Prospectively designed secondary analysis of the ICU Resuscitation Project clinical trial (NCT02837497). SETTING:The 18 pediatric and pediatric cardiac ICUs at ten children's hospitals in the United States. PATIENTS:Children (≤ 18 yr) with an index IHCA event. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary exposure was a prearrest diagnosis of sepsis. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was average diastolic blood pressure (DBP) during CPR. Multivariable regression models controlling for a priori covariates assessed the relationship between sepsis and outcomes. Of 1129 children with index IHCAs, 184 (16.3%) had prearrest sepsis. Patients with sepsis had greater prearrest comorbidities, higher prearrest severity of illness, and higher Vasoactive-Inotropic Scores than patients without sepsis. They more frequently had hypotension as the cause of IHCA, had longer durations of CPR, and more frequently received epinephrine and sodium bicarbonate during CPR. They less frequently achieved survival with favorable neurologic outcome (52/184 [28.3%] vs. 552/945 [58.4%]; p < 0.001; adjusted relative risk, 0.54; 95% CI, 0.43-0.68; p < 0.001). Intraarrest DBPs did not differ between patients with vs. without sepsis. Following IHCA, event survivors with sepsis had higher vasoactive requirements, more frequently experienced hypotension, and continued to have greater mortality rates through 48 hours postarrest. CONCLUSIONS:Children with prearrest sepsis had worse survival outcomes, similar intraarrest DBPs, and greater pre and postarrest severity of illness than children without sepsis.

AIM:We aimed to quantitatively describe vital sign abnormalities prior to pediatric IHCA and evaluate whether the severity of abnormalities was independently associated with survival. METHODS:In a retrospective cohort study using the American Heart Association's Get with The Guidelines-Resuscitation® registry, children with ≥1 min of cardiopulmonary resuscitation (CPR) in an Intensive Care Unit (ICU) from 2007 to 2022 with prearrest vital signs were included. Vital signs most proximate to CPR (10-120 min prior) were classified as abnormal (HR or RR >95th, SBP or DBP <5th percentile for age). Multivariable regression adjusted for age, illness category, prearrest conditions, and prearrest interventions assessed the associations between vital sign abnormalities and outcomes (primary: survival to hospital discharge, secondary: return of spontaneous circulation [ROSC]). RESULTS:Of 2875 IHCA patients meeting inclusion criteria, 1790 (62.3 %) had at least one abnormal vital sign. Patients with vital sign abnormalities were older, had non-surgical illness categories, and higher prevalence of prearrest illnesses and interventions. Low SBP (<5%) was the vital sign with the lowest odds of survival to hospital discharge (aOR 0.56 [95 %CI 0.46-0.68], p < 0.01) and ROSC (aOR 0.63 [95 %CI 0.54-0.73], p < 0.01). There was a stepwise decrease in the adjusted odds of survival for each additional abnormal vital sign (1 vs 0: aOR 0.62 [95 %CI 0.51-0.76], p < 0.01; 2 vs 1: 0.72 [95 %CI 0.53-0.97] p = 0.03; 3 vs 2: 0.53 [95 %CI 0.33-0.86] p < 0.01). CONCLUSIONS:Prearrest vital sign abnormalities are common in pediatric ICU IHCA and independently associated with worse outcomes, emphasizing the need for prompt detection and intervention to improve outcomes.

OBJECTIVE:Assess prevalence of epinephrine before or during the same minute as defibrillation and association with clinical outcomes in pediatric in-hospital cardiac arrest (IHCA). DESIGN:Retrospective cohort study. SETTING:We used 2000-2020 data from the American Heart Association's Get With the Guidelines-Resuscitation Registry. PATIENTS:Children (< 18 yr) with index IHCA with an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least one defibrillation attempt. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary exposure was epinephrine administration before or during the same minute as defibrillation. Study outcomes were survival to hospital discharge (primary outcome), return of spontaneous circulation (ROSC) for greater than or equal to 20 min, and survival with favorable neurologic outcome. Propensity-score matching was used for confounding adjustment. Among 492 pediatric IHCA index events with an initial shockable rhythm, median age was 7 years and 351 (71%) were in the ICU. Overall, 232 (47%) children received either epinephrine before defibrillation (29%) or during the same minute as defibrillation (18%). In unadjusted analyses, proportions of survival to hospital discharge (37.1% vs. 51.2%), ROSC (74.6% vs. 84.6%), and survival with favorable neurologic outcome (22.1% vs. 40.4%) were lower in the epinephrine before or during the same minute as defibrillation group. However, in adjusted analyses using propensity score matching with exact matching on time to defibrillation category, epinephrine before or during the same minute as defibrillation was not associated with hospital survival (odds ratio [OR] 0.84, 0.46-1.56), ROSC (OR 0.97, 0.48-1.96), or favorable neurologic outcome (OR 0.52, 0.27-1.00). CONCLUSIONS:Contrary to current guidelines, nearly 50% of pediatric IHCA due to an initial shockable rhythm receive epinephrine before, or during the same minute, as first defibrillation. Although survival outcomes were numerically lower in epinephrine before defibrillation group, the association was not statistically significant.

Introduction:Measurement of coronary perfusion pressure (CoPP) and diastolic blood pressure (DBP) during cardiopulmonary resuscitation (CPR) is important for titration of physiologic-directed CPR. However, agreement between different calculation methods and their relative performance as outcome discriminators are not well established. Methods:Four calculation methods, differentiated by sampling technique, were retrospectively applied to pressure waveforms from piglet CPR: late diastole (CoPP65, DBP65), mid-diastole (CoPP50, DBP50), diastolic minimum (CoPPmin, DBPmin), and diastolic mean (CoPPmean, DBPmean). Intermethod agreement was assessed by Bland-Altman analysis and Cohen's kappa statistic. Logistic regression was used to evaluate performance in discriminating return of spontaneous circulation (ROSC) and to identify optimal thresholds. Results:Relative to CoPP65, measurements by CoPP50, CoPPmin, and CoPPmean were within 5 mmHg limits of agreement (LOA) in 97%, 64%, and 99% of instances with kappa 0.88, 0.76, and 0.91, respectively. Relative to DBP65, measurements by DBP50, DBPmin, and DBPmean were within 5 mmHg LOA in 98%, 71%, and 99% of instances with kappa 0.90, 0.80, and 0.91, respectively. The areas under the ROC curves (AUC) for CoPP65, CoPP50, CoPPmin, and CoPPmean were 0.777, 0.792, 0.787, and 0.788, and optimal thresholds to discriminate ROSC were 15.3, 15.8, 12.3, and 14.7 mmHg, respectively. The AUCs for DBP65, DBP50, DBPmin, and DBPmean were 0.813, 0.827, 0.833, and 0.826, and optimal thresholds to discriminate ROSC were 28.6, 27.3, 26.2, and 29.7 mmHg, respectively. Conclusions:During piglet CPR, measurements by late diastole, mid-diastole, and diastolic mean strongly agreed, whereas those at diastolic minimum were more discrepant. All methods performed similarly in discrimination of ROSC.

BACKGROUND:Black patients have worse outcomes after in-hospital cardiac arrest (IHCA). Whether these racial disparities are associated with medical emergency team (MET) evaluation prior to IHCA remains unknown. METHODS:A retrospective cohort study of adults age ≥ 18 years from the American Heart Association Get With The Guidelines® Resuscitation registry who had an IHCA between 2000 and 2021 with acute physiologic decline (modified early warning score [MEWS] ≥ 3) during the 24 h prior to IHCA. A propensity-weighted cohort was constructed to balance confounders between Black and White patients. The association between race and MET evaluation was quantified with weighted multivariable logistic regression. RESULTS:Among 354,480 patients, 88,507 met the initial inclusion criteria, of which 29,714 patients (median age 69 [IQR 58-79] years, 42.5% female, and 26.9% Black) had acute physiologic decline during the 24 h prior to IHCA. Among patients with acute physiologic decline, 4102 (13.8%) patients had a preceding MET evaluation before IHCA. Rates of MET evaluation prior to cardiac arrest did not differ significantly between Black and White patients with acute physiologic decline (aOR 1.02, 95% CI 0.94-1.11, p = 0.62). CONCLUSIONS:Though racial disparities in IHCA outcomes exist, this study did not detect a difference in rates of MET evaluation prior to IHCA among patients with acute physiologic decline as a potential mechanism for these disparities.