Aortic stiffness can be measured using aortic pulse wave velocity (PWV), calculated from peripheral arterial waveforms. However, this method has not been validated in children. We sought to determine whether PWV could be feasibly measured by tonometry and accurately derived from the arterial waveforms available in critically ill infants and children. Applanation tonometry was used to measure brachio-femoral or carotid-femoral PWV (b/cfPWV) in hospitalized hemodynamically stable, pre-pubertal children with an indwelling arterial catheter. Peripheral arterial line waveforms were converted into ascending aortic waveforms by a model transfer function. We found that the effective reflecting distance (EfRD) calculation used in adults overestimated b/cfPWV in children. We derived a new EfRD equation that yielded a better agreement between measured and estimated PWV (R^2 = 0.30, p < 0.05). Estimating PWV from arterial waveforms data eliminates the need for tonometry, allowing larger sample sizes of infants and children to be included in future cardiovascular disease and development studies. ### Competing Interest Statement Dr. Bates is the Founder and CEO of LSF Medical Solutions and Dr. Tomasson serves as Chief Medical Officer. Harald Stauss is the creator of Hemolab. LSF Medical Solutions LLC and Hemolab neither provided nor received funding for the conduct of this work. ### Funding Statement This study did not receive any funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of the University of Iowa gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

This study examines sex-specific effects of developmental sertraline exposure on cardiac function and gene expression before and after myocardial infarction (MI) in mice. Female C57BL/6 mice (10 weeks) received intraperitoneal sertraline (5 mg/kg/day, n = 37) or saline (n = 20) before mating, during pregnancy, and postnatally to pups (1.5 mg/kg/day, postnatal Days 0-14). MI in offspring was induced at 10 weeks by left coronary artery ligation. Randomly chosen offspring (sham n = 8 and MI n = 26 per sex) underwent baseline echocardiography and at 10 weeks post-MI if surviving. Serotonin- and estrogen-related gene expression was analyzed. Before MI, sertraline-exposed females had lower heart rate (649.1 ± 102.0 vs. 692.9 ± 38.4 bpm, n = 34), increased end-systolic volume, and reduced ejection fraction (80.7 ± 6.3% vs. 83.9 ± 3.5%; p < 0.05). Exposed males also had lower heart rates (665.9 ± 32.7 vs. 683.3 ± 47.9 bpm, n = 34, p < 0.05). Post-MI, both sexes remodeled similarly (scar size, ischemic-zone fraction); sertraline-exposed males had higher scar-zone collagen (p < 0.05) and a nonsignificant lower survival trend than females. Sertraline altered serotonin-related gene expression (Htr2a, Htr2b, Slc6a4), particularly in male sham mice. Developmental sertraline exposure induces sex-specific cardiac changes, potentially affecting post-MI outcomes, with males showing more structural and survival impairments.

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.

BACKGROUNDAnnually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA.METHODSUsing 2000-2020 data from the American Heart Association’s (AHA) Get with the Guidelines® -Resuscitation (GWTG-R) registry, we identified children > 48 hours of life and ≤ 18 years who had an IHCA from initial VF/pVT and received defibrillation.RESULTSThere were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥ 4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation.CONCLUSIONSIn pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.

Selective serotonin reuptake inhibitors (SSRIs) are prescribed in 15% of pregnancies in the United States for depression. Maternal use of SSRIs has been linked to an increased risk of congenital heart defects, but the exact mechanism of pathogenesis is unknown. SSRIs, including sertraline, are permeable to the placenta and can produce direct fetal exposure. Previously, we have shown decreased cardiomyocyte proliferation, left ventricle size, and cardiac expression of the serotonin receptor 5-HT2B in the offspring of mice exposed to the SSRI sertraline relative to the offspring of saline-exposed mice. Using a mouse model of in utero plus neonatal sertraline exposure, we observed lengthened peak-to-peak time of calcium oscillation (saline 784 ± 76 ms; sertraline 1,121 ± 130 ms, P < 0.001) and decreased expression of critical genes in calcium regulation. We also observed significant upregulation of specific microRNAs (miRNAs) that modulate serotonin signaling in neonatal cardiac tissues (Slc6a4: miR-223-5p, miR-92a-2-5p, miR-182-5p; Htr2a: miR-34b-5p, miR-182-5p; Htr2b: miR-223-5p, miR-92a-2-5p, miR-337-5p) (P < 0.05) with corresponding levels of the target mRNAs downregulated (Slc6a4 0.73 ± 0.05; Htr2a 0.67 ± 0.04; Htr2b 0.72 ± 0.03; all P < 0.01), resulting in decreased production of the cognate proteins. Adult mice at 10 wk showed altered cardiac parameters including decreased heart rates in males (saline 683 ± 8 vs. sertraline 666 ± 6 beats/min, P < 0.05) and ejection fraction in females (saline 83.9 ± 0.6% vs. sertraline 80.6 ± 1.1%, P < 0.05). These findings raise the question of whether sertraline exposure during development may increase the potential risk for cardiac disease when subjected to stress.NEW & NOTEWORTHY Sertraline exposure during development decreased the expression of critical genes in calcium regulation and lengthened periods in calcium oscillation in neonatal cardiomyocytes. Sertraline upregulated specific microRNAs that may modulate serotonin signaling in neonatal cardiac tissues, which corresponded with a decrease in the levels of the corresponding target mRNAs. Although the echocardiograms in our adult mice suggest a mild phenotype associated with sertraline exposure, these upregulated microRNAs (miRNAs) have been linked to adult cardiovascular disease and heart failure.

Background: Contrary to current guidelines, administration of epinephrine before first defibrillation for shockable in-hospital cardiac arrest (IHCA) is common in adults and associated with lower survival. Whether these findings are also present in pediatric IHCA remains unknown. Methods: We used 2000-2020 data from the Get With the Guidelines®—Resuscitation registry to identify children (<18 years) with index IHCA due to an initial shockable rhythm of ventricular fibrillation or pulseless ventricular tachycardia and at least 1 defibrillation attempt. Study outcomes were event survival, defined as return of spontaneous circulation for > 20 minutes, survival to hospital discharge and favorable neurologic survival. Inverse probability of treatment weighting (IPTW) using propensity scores was used to adjust for confounding . Results: Among 492 pediatric IHCA index events (median [IQR] age, 7 years [0.75 to 14 years]; 351 [71%] in the ICU), 142 (29%) children with an initial shockable rhythm received epinephrine before defibrillation. Subjects receiving epinephrine before defibrillation had longer times to defibrillation compared to those receiving defibrillation first (median [IQR]: 4 minutes [2 to 8] vs. 1 minute [0 to 2]). Rates of event survival (72.7% vs. 82.8%), survival to hospital discharge (36.4% vs. 47.9%), and favorable neurologic survival (18.9% vs. 33.1%) were lower in the epinephrine before defibrillation group, Table). However, in adjusted analyses using IPTW, epinephrine before defibrillation was not associated with survival outcomes (Table). Conclusions: Nearly one in three pediatric IHCA with initial shockable rhythm receives epinephrine before defibrillation in contrast with recommended guidelines. However, unlike adults with IHCA, we did not identify a clear association between epinephrine before defibrillation and survival.

BackgroundThe guideline recommended chest compression depth, rate, and recoil are essential factors for the return of spontaneous circulation (ROSC) in cardiopulmonary resuscitation (CPR). A pediatric resuscitation collaboration recently demonstrated that healthcare providers fail to meet the American Heart Association (AHA) guidelines, with the greatest difficulty being in achieving chest compression depth targets in infants. We hypothesized that the use of the heel of one hand [open palm technique (OPT)] will increase chest compression depth in infants compared to standard CPR techniques [two-finger technique (TFT), two thumb-encircling hand technique (TTT)].MethodsA prospective, randomized, single-center study was completed using an infant manikin. Thirty pediatric critical care providers performed 2 min of CPR for each technique followed by 5 min of rest. Each participant completed a survey at the end that assessed the difficulty level in order to assess the feasibility of this new technique.ResultsThe mean chest compression depth for the OPT was significantly deeper compared to TFT (2.61± 0.63 cm vs. 2.25 ± 0.54 cm, p = 0.0004) but not significantly deeper compared to TTT (2.43 ± 0.46 cm, p = 0.0820). OPT was graded as the easiest technique, followed by TTT (2.20 ± 0.76 vs. 3.17 ± 0.95, p < 0.0001) and then TFT (3.38 ± 0.83, p < 0.0001).ConclusionThe use of OPT for infant CPR resulted in improved chest compression depth. OPT was considered the easiest technique compared to standard infant CPR techniques, thus making it feasible to perform. Importantly, all providers failed to meet the AHA infant chest compression depth goal of 4 cm, regardless of the technique. Future research is needed to optimize CPR technique and performance to achieve targeted chest compression depth in infants.

Pediatric in-hospital cardiac arrest (IHCA) effects 15,000 American children annually. 1 Holmberg M.J. et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019; 12: e005580 Crossref PubMed Scopus (198) Google Scholar Physiologic intra-arrest monitoring, specifically of end-tidal carbon dioxide (ETCO2) and diastolic blood pressure (DBP), has been associated with improved outcomes in pre-clinical studies and in adults, but a paucity of pediatric evidence exists. In 2013, an American Heart Association (AHA) consensus statement recommended using DBP and/or ETCO2 during CPR to monitor and guide CPR quality. 2 Meaney P.A. et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013; 128: 417-435https://doi.org/10.1161/CIR.0b013e31829d8654 Crossref PubMed Scopus (673) Google Scholar Subsequent AHA guidelines continue to suggest ETCO2 and DBP monitoring of CPR quality, but highlight that specific values to guide therapy are not well established. 3 de Caen A.R. et al. Part 12: Pediatric advanced life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132: S526-S542https://doi.org/10.1161/CIR.0000000000000266 Crossref PubMed Scopus (384) Google Scholar , 4 Topjian A.A. et al. Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142: S469-S523https://doi.org/10.1161/CIR.0000000000000901 Crossref PubMed Scopus (180) Google Scholar

Background: We previously reported that sertraline reduced left ventricular size, acutely slowed down mouse pup growth, and significantly reduced calcium oscillations in cardiomyocytes (p<0.05), and that the sertraline-induced up-regulations of certain miRNAs might epigenetically modulate cardiac functional gene expression of serotonin signaling pathway with down-regulation of Htr2a, Htr2b and Slc6a4 mRNAs and corresponding proteins (p<0.05). Here we hypothesize that sertraline effect is gender related when subjected to a stress at adult. Method: C57BL/6 adult female mice received sertraline (5 mg/kg/d IP) or saline 5 days before mating, throughout pregnancy until time of delivery, and the pups were given 1/3 adult dose before weaning. At age of 10 weeks, offspring mice were subjected to echocardiograms before myocardial infarction (MI) induced by left anterior descending coronary artery ligation. Mice were divided into groups according to sex, and treatments (saline vs sertraline, & MI vs sham). Ten weeks post-MI, echocardiograms were performed again for the survived mice. Results: Female mice before MI had significantly reduced heart rates (649±18 vs 691±7 bmp), increased end systolic volumes (4.5±0.6 vs 3.2±0.1 μL), and decreased ejection fractions (EF) (80.6±0.7% vs 83.9±0.6%) (n=34, p<0.05). Male mice did not show the significant effects on baseline. Two weeks post-MI, Females had survival rates reduced by sertraline (74.3% vs saline 100%, p=0.0833). Males exhibited MI intolerance with lower survival rates (66.8% vs saline 67.2%), and ODD ratio was deteriorated (24.35 vs female 1.00, p=0.0317). At the end point, the survived mice showed variable MI-induced ischemia zones (47.5±13.2%) corresponding to variable EF (30.0±14.9%). The cardiac functions became not significant different in both male and female survived mice. Concluding Remarks: The cardiac potential risk was observed in the baseline and in the earlier MI phase of female mice with in utero plus neonatal sertraline exposure, while male mice showed different pattern of sertraline effect. Such sex-dependent cardiac effects of maternal SSRI exposure in adult offspring deserve to be detailly studied by using mouse models for heavy use of SSRIs in pregnant women.

Introduction: Approximately 15,200 children suffer an in-hospital cardiac arrest (IHCA) annually, and 10-20% will have ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT). Timely defibrillation is critical for shockable rhythms, however current data are lacking on outcomes when > 1 shock is required for termination of VF/pVT. Methods: From the AHA Get With The Guidelines ® -Resuscitation registry, we identified children < 18 years of age who had IHCA from initial VF/pVT and received > 1 shock from 2000-2020. Patients were analyzed according to total number of shocks received: 2 shocks, 3 shocks, or > 4 shocks. Multivariable logistic regression models were used to test the association between number of shocks and return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favorable neurologic outcome. Results: 436 patients met inclusion criteria and received > 1 shock for VF/pVT. Median age was 8 years [IQR, 0.9,15.0]. Patients that required > 4 shocks were older patients (11 years [1.0-15.0; p=0.013]). A higher percentage of patients receiving > 4 shocks had renal insufficiency (14% vs. 7% for 2 shocks vs. 6% for 3 shocks, p = 0.041). Patients receiving > 4 shocks vs. 2 shocks were less likely to achieve ROSC (OR 0.40 [0.23,0.68]; p=0.0009). There was no statistically significant difference in survival to hospital discharge for patients receiving 2 shocks (42%), 3 shocks (39%), or > 4 shocks (32%) or survival to hospital discharge with favorable neurologic outcome. Conclusion: There was no significant association between the number of shocks and survival to hospital discharge or survival to hospital discharge with favorable neurologic outcome. ROSC was significantly less in patients with > 4 shocks for VF/pVT compared to 2 shocks. Further research is needed to characterize energy dosing when > 1 shock is needed for VF/pVT.

Selective serotonin reuptake inhibitors (SSRIs) are antidepressants prescribed in 10% of pregnancies in the United States. Maternal use of SSRIs has been linked to an elevated rate of congenital heart defects, but the exact mechanism of pathogenesis is unknown. Previously, we have shown a decrease in cardiomyocyte proliferation, left ventricle size, and reduced cardiac expression of the serotonin receptor 5-HT 2B in offspring of mice exposed to the SSRI sertraline during pregnancy, relative to offspring of untreated mice. These results suggest that disruption of serotonin signaling leads to heart defects. Supporting this conclusion, we show here that zebrafish embryos exposed to sertraline develop with a smaller ventricle, reduced cardiomyocyte number, and lower cardiac expression of htr2b relative to untreated embryos. Moreover, zebrafish embryos homozygous for a nonsense mutation of htr2b ( htr2b sa16649 ) were sensitized to sertraline treatment relative to wild-type embryos. Specifically, the ventricle area was reduced in the homozygous htr2b mutants treated with sertraline compared with wild-type embryos treated with sertraline and homozygous htr2b mutants treated with vehicle control. Whereas long-term effects on left ventricle shortening fraction and stroke volume were observed by echocardiography in adult mice exposed to sertraline in utero, echocardiograms of adult zebrafish exposed to sertraline as embryos were normal. These results implicate the 5-HT 2B receptor functions in heart development and suggest zebrafish are a relevant animal model that can be used to investigate the connection between maternal SSRI use and elevated risk of congenital heart defects.

Introduction: Survival of adult patients with COVID-19 who had an in-hospital cardiac arrest (IHCA) are poor. Characteristics and outcomes for pediatric IHCA patients with COVID-19 are unknown. Hypothesis: We hypothesized that pediatric COVID-19 patients would have worse survival outcomes when compared to non-COVID patients. Methods: A multicenter, multinational cohort of pediatric IHCA in the pediRES-Q collaborative were reviewed (March 1, 2020 - April 1, 2021). We characterized patients with COVID-19 compared to patients without COVID-19 and investigated whether COVID-19 was associated with survival outcomes using multivariate logistic regression with mixed effects. Results: We identified 362 pediatric IHCAs of which 14 were COVID-19 positive. For non-COVID-19 vs COVID-19 patients respectively, median [Q1; Q3] age was 1.0 [0.3; 7.1] vs. 7.1 [1.5; 14.0] years and 42% vs. 43% were female. Immediate cause of arrest was hypotension: 8% vs. 43%, respiratory decompensation: 19% vs. 21%, and hypoxia 22% vs. 36% for non-COVID-19 vs. COVID-19 patients. For non-COVID-19 vs COVID-19 patients, total CPR duration was 10 [4; 33] min vs 19 [5; 33] min (for non-return of spontaneous circulation (ROSC) cases only: 35 [20; 55] min vs 34 [24; 34] min). For non-COVID-19 vs COVID-19 patients, ROSC was 79% vs. 57%, aOR: 0.48 (95% CI: 0.24-0.98), survival to hospital discharge was 45% vs. 29%, aOR: 0.63 (95% CI: 0.25-1.57) and survival with favorable neurological outcome was 39% vs. 21%, aOR: 0.51 (95% CI: 0.16-1.65). Conclusions: In a pediatric resuscitation quality improvement collaborative, pediatric IHCA patients with COVID-19 were older when compared to non-COVID-19 patients. Median CPR duration was >30 minutes for COVID-19 non-survivors, COVID-19 patients had lower chance of ROSC when compared to non-COVID-19 patients but considerably better survival outcomes than those reported for adults.

Introduction: The American Heart Association (AHA) CPR guidelines states that effective chest compression depth, rate and recoil are essential factors for establishment of return of spontaneous circulation. A recent survey from an international pediatric resuscitation collaborative showed that healthcare providers failed to meet the metrics of the AHA guidelines, with the greatest difficulty in achieving targeted chest compression depth in infants. The recommended techniques for infant compression include two finger (TFT) or two-thumb technique (TTT). We hypothesized using the heel of one palm (open palm technique, OPT) in infants will result in improved chest compression depth with decreased provider fatigue. Methods: Each participant performed three techniques including TFT, TTT, and novel open-palm technique (OPT) with randomization for sequence of techniques for each participant. Each technique was performed for 2 minutes followed by a 5-minute rest period on an infant manikin. Data were collected through Zoll R series defibrillators on chest compression depth, rate, and fraction. At the end of the study, each participant filled out a survey for difficulty level, finger fatigue, and rescuer fatigue. Results: Thirty pediatric critical care providers participated in the study consisting of 16 nurses, 9 respiratory therapists, 3 fellows, 2 nurse practitioners. The mean chest compression depth for OPT was significantly deeper (2.61 ± 0.63 cm) in comparison to TFT (2.25 ± 0.54 cm, p= 0.0004) but not significantly deeper in comparison to TTT (2.43 ± 0.46 cm, p= 0.0820). There were no significant differences between the three techniques in chest compression rate or chest compression fraction. The finger fatigue and rescuer fatigue surveys were graded from 0-10 with 10 being the most fatigue. OPT showed significantly less finger and rescuer fatigue in comparison to TTT and TFT (p<0.05). Conclusion: This study demonstrated that OPT generated improved chest compression depth with considerably less rescuer and finger fatigue. However, chest compression depth with all three techniques failed to meet the AHA infant goal of 4 cm. Further research is needed to optimize CPR performance to achieve the targeted chest compression depth in infants.

Background Amplitude spectral area (AMSA) predicts termination of fibrillation (TOF) with return of spontaneous circulation (ROSC) and survival in adults but has not been studied in pediatric cardiac arrest. We characterized AMSA during pediatric cardiac arrest from a Pediatric Resuscitation Quality Collaborative and hypothesized that AMSA would be associated with TOF and ROSC. Methods and Results Children aged <18 years with cardiac arrest and ventricular fibrillation were studied. AMSA was calculated for 2 seconds before shock and averaged for each subject (AMSA‐avg). TOF was defined as termination of ventricular fibrillation 10 seconds after defibrillation to any non‐ventricular fibrillation rhythm. ROSC was defined as >20 minutes without chest compressions. Univariate and multivariable logistic regression analyses controlling for weight, current, and illness category were performed. Primary end points were TOF and ROSC. Secondary end points were 24‐hour survival and survival to discharge. Between 2015 and 2019, 50 children from 14 hospitals with 111 shocks were identified. In univariate analyses AMSA was not associated with TOF and AMS‐Aavg was not associated with ROSC. Multivariable logistic regression showed no association between AMSA and TOF but controlling for defibrillation average current and illness category, there was a trend to significant association between AMSA‐avg and ROSC (odds ratio, 1.10 [1.00‒1.22] P =0.058). There was no significant association between AMSA‐avg and 24‐hour survival or survival to hospital discharge. Conclusions In pediatric patients, AMSA was not associated with TOF, whereas AMSA‐avg had a trend to significance for association in ROSC, but not 24‐hour survival or survival to hospital discharge. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02708134.

Introduction: Survival after in-hospital cardiac arrest (IHCA) has been reported to be worse for arrests at night or during weekends.This study aimed to determine whether measured cardiopulmonary resuscitation (CPR) quality metrics might explain this difference in outcomes. Methods: IHCA data was collected by the Pediatric Resuscitation Quality (pediRES-Q) collaborative for patients <18 years. Metrics of CPR quality [chest compression rate, depth and fraction] were measured using monitor defibrillator pads, and events were compared by time of day and day of week. Results: We evaluated 6915 sixty-second epochs of chest compression (CC) data from 239 subjects between October 2015 and March 2019, across 18 hospitals. There was no significant difference in CPR quality metrics during day (07:00 22:59) versus night (23:00 06:59), or weekdays (Monday 07:00 to Friday 22:59) versus weekends (Friday 23:00 to Monday 06:59).There was also no difference in rate of return of circulation. However, survival to hospital discharge was higher for arrests that occurred during the day (39.1%) vs. nights (22.4%, p = 0.015), as well as on weekdays (39.9%) vs. weekends (19.1%, p = 0.003). Conclusions: For pediatric IHCA where CC metrics were obtained, there was no significant difference in CPR quality metrics or rate of return of circulation by time of day or day of week. There was higher survival to hospital discharge when arrests occurred during the day (vs. nights), or on weekdays (vs. weekends), and this difference was not related to disparities in CC quality.

The American Heart Association (AHA) recommends first defibrillation energy dose of 2 Joules/kilogram (J/kg) for pediatric cardiac arrest with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). However, optimal first energy dose remains unclear. Methods: Using AHA Get With the Guidelines-Resuscitation (R) (GWTG-R) database, we identified children <= 12 years with IHCA due to VF/pVT. Primary exposure was energy dose in J/kg. We categorized energy doses: 1.7-2.5 J/kg as reference (reflecting 2 J/kg intended dose), <1.7 J/kg and >2.5 J/kg. We compared survival for reference doses to all other doses. We constructed models to test association of energy dose with survival; adjusting for age, location, illness category, initial rhythm and vasoactive medications. Results: We identified 301 patients <= 12 years with index IHCA and initial VF/pVT. Survival to discharge was significantly lower with energy doses other than 1.7-2.5 J/kg. Individual dose categories of <1.7 J/kg or >2.5 J/kg were not associated with differences in survival. For patients with initial VF, doses >2.5 J/kg had worse survival compared to reference. For all patients <= 18 years (n = 422), there were no differences in survival between dosing categories. However, all <= 18 with initial VF receiving >2.5 J/kg had worse survival. Conclusions: First energy doses other than 1.7-2.5 J/kg are associated with lower rate of survival to hospital discharge in patients <= 12 years old with initial VF/pVT, and first doses >2.5 J/kg had lower survival rates in all patients <= 18 years old with initial VF. These results support current AHA guidelines for first pediatric defibrillation energy dose of 2 J/kg.

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.

OBJECTIVES:Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative.METHODS:From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated.RESULTS:All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions.CONCLUSIONS:Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.