Those of you for sticking around this late in the day, we appreciate it. I have nothing to disclose. As a little bit of background, estimated over 15,000 children in the United States every year have an in-hospital cardiac arrest. And the good news is that the vast majority of them, about 81% of patients, achieve return of spontaneous circulation. So once we get a pulse back, all the effort goes from resuscitation to the post-arrest care. And we know that provision of high-quality post-arrest care is really important for these patients. But the actual management pieces are evolving. And so in some children, we consider the use of extracorporeal life support. This can be a really important therapy for restoring adequate hemodynamics, which we know is important for a neurologic function. When we talk about pediatric ECLS, it can get a little bit muddy. And so for the sake of clarification, I want to go over a couple of definitions we used for our study. So the use of extracorporeal cardiopulmonary resuscitation or ECPR, defined as the deployment and initiation of ECLS during active chest compressions or within 20 minutes of return of spontaneous circulation. And this is the current definition from the ELSO organization. And then in this study, we talk about post-arrest ECLS, which we defined as initiation of ECLS after 20 minutes of spontaneous circulation. And I should mention at this point as well that ECPR has quite a robust literature surrounding it. We know what sort of patients receive ECPR and what their outcomes are likely to be. The literature surrounding post-arrest ECLS is sparse. There are a few small studies, but this is not well-defined in the literature. And so we really sought to better describe these patients. This is a retrospective cohort study. We used the PD Rescue Database, which is a pediatric resuscitation quality improvement database. So this is a multi-center organization of children's hospitals who go through QI initiatives together, share their data in this database and contribute. And so this is a really rich database. And interestingly, there are cardiac ICU patients in this database, but the majority of the patients contributed are in a general pediatric ICU. Some of them may be cardiac, some of them may be non, but it's a more general pediatric ICU population. We included all patients aged 18 years or less in the study time. We looked at children who were where an ECPR was activated, who had return of spontaneous circulation and then were subsequently cannulated for ECLS. It gets a little bit messy, so it's sort of a visual. So patients have an arrest event, they receive chest compressions, they have an ECPR activated, and then they get a pulse back. They return to spontaneous circulation for best we can tell 20 minutes. And then ECLS is initiated. Our primary outcomes were survival to ICU discharge, and then favorable neurologic outcome, which we defined as a PCPC of 2 or less or unchanged from their baseline, which is consistent with the current literature. Looking at our results, here are our demographics. We had 56 patients. Their median age was 0.8 years. You can see of the children with race recorded, the largest group was white patients. And the small proportion, 14%, identified as Hispanic ethnicity. Here's our breakdown by diagnosis type. So the largest portion here is medical cardiac. Surgical cardiac and medical non-cardiac are equally divided. And then a small proportion of surgical non-cardiac and trauma. So you can see here that while cardiac is a large proportion, there is still quite that green section is all medical non-cardiac patients. This is a fairly sick cohort. So about 60% had a vasoactive agent in place at the time of their cardiac arrest event. 50% of them were in the PICU and only 18% in the cardiac ICU. The remainder of patients in the study were in either emergency department or procedural areas. And then 11% of patients had a single ventricle diagnosis. Looking at the initial rhythm, you can see that the vast majority of patients had either PEA, asystole, or bradycardia. That purple shaded portion is ventricular fibrillation and VTAC with and without a pulse. And then a small proportion of other rhythms. And of note, we had a long duration of CPR. So 38 minutes was the median duration, although there was quite a lot of variability between the 11-56 minutes was the IQR. We look at the outcomes of these patients. We had 56 patients total, 30 survived ICU discharge, so a 54% rate of survival with a relatively long duration of arrest. And most importantly to us and to patients and families, 83% of survivors had a good neurologic outcome. The main points that I wanted to touch on in our discussion, survival in this cohort was higher than we expected. So if we look at the ELSO data from the 2016 report, looking at patients with a diagnosis of cardiac arrest, 44% of them survived to hospital discharge, compared to 54% surviving to ICU discharge in our group. Of note, that's 52% to hospital discharge, although that wasn't our primary outcome. 83% of our survivors had a favorable neurologic outcome, which is important to us and also was higher than we had anticipated. Some reasons for this might be, one, our study population is a group of children's hospitals with the resources to conduct resuscitation quality improvement initiatives, and then also to contribute data, which is a fairly resource-intensive commitment to this database. And so it may be that that's part of what's driving these outcomes. But also, we don't have any other large studies with great numbers to tell us what the survival rate is in this population. And so that's important. And then one of the other striking findings is that only 25% of the patients in our cohort were surgical cardiac patients. When you look at the eCPR literature, it's a much higher proportion. So 59% in Dr. Bembeya's Get With The Guidelines and also emerging study. And then in a review of all eCPR and post-arrest from 2008, they had 75% were post-surgical cardiac patients. And so this is much more representative of the general PICU patient population, which I think is important because the most recent AHA guidelines, we don't have adequate evidence to recommend for eCPR. Of course these patients went on ECLS after resuscitation, but they were activated as eCPR. So they were eCPR candidates. A couple of really important limitations in this work. One is we do not have access to the data required to tell us the time from the arrest event to ECLS initiation. And that's important. We would like to know when these patients went on. And then two, we acknowledge this is a really difficult to define group. Even with high-quality reliable data, it's really hard to tell. And so there's certainly potential for misclassification. We're doing the best that we can with the data we have. But without higher-definition data, it's really hard to know. I will say that we were worried about misclassification of these patients. Did they actually go on as eCPR? We've looked at the eCPR patients as a separate cohort and a separate study from the same group of patients. And they differ in a lot of ways. So we hope that these are actually two distinct populations. So in conclusion, in this cohort of patients who had an activation eCPR, got a pulse back, then went on ECLS in the post-arrest period, we saw really high rates of survival with good neurologic outcome despite a prolonged resuscitation. And as our next steps, we're looking at the post-arrest ECLS patients among all patients, not just those identified as an eCPR initially, but all patients who received ECLS in the post-arrest period. A huge thank you to our research group. They've been really wonderful in supporting this work. And a huge thank you also to the PD Rescue sites and their patients and staff. Thank you all for your attention. I'd be happy to take any questions or comments you might have.

extracorporeal life support

pediatric resuscitation

cardiac arrest

neurological outcome

hemodynamics