SCCM Resource Library-Star Research Presentations: Resuscitation

Video Transcription

Good afternoon. My name is Jeremiah Duby. I'm a critical care pharmacist at UC Davis Medical Center And I'll be the moderator for the session really quickly. We're moving the second  Session as scheduled to the first while we fix the slides for the first nothing to see over there. I  Would say move to the center of the row, but it seems a little silly. It's a lace it wherever you like  exit doors are behind you please silence your cell phone and  You can get CE for the stock through the app  Speakers will disclose their conflicts  You may take photographs, but please do not publish them And if you would like you can share or tweet at hashtag CCC for nine the first speaker  Is up doll balala he will be presenting on?  Pre-arrest is that right pre-arrest echocardiographic changes could they predict?  cardiac arrest and hospitalized children  Thank you for this wonderful opportunity good afternoon everyone. I know it's  Almost close to end of the day, but thanks for coming and listening to our talk. I  I'm honored and privileged to be  Invited for the star research award presentation  First of all I would like to acknowledge  my students who have put in a lot of hard work on this project Charleston West who just came in and  Jose Augustin Gutierrez Gomez  student from University of UDEM in Mexico Monterey and  They they put in a lot of work on analyzing EKG together and so thanks to them  I do not have any disclosure to report  literature related to Adult sudden cardiac death suggests that pre-arrest changes in EKG variables can be used to predict cardiac arrest  There is no similar data on pre-arrest changes in the EKG variables in children prior to in-hospital cardiac arrest  So in this particular study  The adult  Intensivist were able to demonstrate certain EKG changes before the arrest But in this study, they looked at the EKG changes 24-hour prior to arrest  Sinus pauses and AV block were commonly seen prior to PEA and bradycystole  Caused by respiratory events which suggests that hypoxia can cause impaired nodal function prior to leading to cardiac arrest  RR and QRS prolongation were primarily found in those which were related to multi-organ dysfunction and  that suggested myocardial conduction delay caused primarily by sequelae of severe multi-organ disease including  hypotension These findings agree with experimental data showing that hypoxia in guinea pig and rabbit hearts  Display delayed conduction through sinus node and AV node  in this particular study  Certain  Specific EKG changes were reported prior to in-hospital cardiac arrest in adult  again, there is Some data which suggests that pre-arrest changes in the EKG variables can be used to predict cardiac arrest in adults  But there is no similar data on pre-arrest changes in EKG variables in children prior to in-hospital cardiac arrest  So our hypothesis was specific pre-arrest EKG changes do occur prior to in-hospital cardiac arrest in children  Patient characteristics and central monitor data on pre-arrest EKG variables were collected for pediatric in-hospital cardiac arrest  occurring between December 2017 and December 2019 at our Children's Hospital of San Antonio  Pre-arrest cardiac rhythm and EKG parameters were evaluated in 30-second epochs During five minutes prior to initiation of chest compressions  EKG intervals, which we reviewed were RR, PR, QRS, QT, QTC and  J-point and ST point positions  so again, this is just a clip from the central monitor, which was downloaded pre-arrest and  Then we looked at specific intervals  At 30-second epochs in five-minute time frame before the chest compressions were initiated  The initial and peak EKG intervals and the initial and nearer values of J-point and ST and T-wave positions  within five minutes prior to arrest were compared using two-tailed student t-test with a significant p-value of less than or equal to 0.05  A total of 335 EKG tracings were reviewed from 37 in-hospital cardiac arrest among 29 children  between this time frame The median age was five months. The documented cardiac arrest rhythms were PEA in 21, bradycardia in 12, asystole in 3 and ventricular fibrillation in 1  So what were the findings? So we saw that RR interval  were increased from 0.52 to 1.38 median value  PR interval increased from 0.12 to 0.16 median  QRS complex also showed increase from 0.08 to 0.12 and  QT and QTC also showed some change as you can see and there was  depression of the J-point and the ST segment from the initial time point which was five minute before the compressions were begun  So there was a significant change in all EKG variables except J-point and ST segment measurements within five minutes prior to the arrest  RR interval prolongation was the most frequent and earliest EKG change prior to arrest  So we wanted to look at if RR interval change was significant Was it just because they were becoming bradycardic?  And so we wanted to look at what happened first the change in the RR interval or they were  simultaneous with the heart rate significantly going down and so we looked at the median time between the peak RR interval and drop in heart rate below 60  which would alert the team to initiate chest compression or do something and So we found that it was 30 second with IQ or 0 to 90 seconds  These were our outcomes so we found that 88% of our patients had ROSC and  survival to ICU discharge The median time to ROSC was 7 minute 30 seconds We found that 27% almost one-third of our patients had hypokalemia within 24 hours of the event  of Within 24 hours prior to the event and only 2.7 percent cases had hyperkalemia  within that time frame Hypokalcemia was seen in 8.1 percent of cases  24 hours prior to the event and what was very  Significant was that almost half of the patients were exposed to dexmedetomidine within 24 hours prior to the event  Again we looked at these things because we wanted to make sure that these were not the major confounders  EKG trends can be identified prior to in-hospital cardiac arrest in children  These EKG changes could be potentially used in creating innovative cardiac arrest alert system for monitors  What are some of the future directions? We would like to evaluate EKG intervals at two other time points that is at one hour and six hours prior to arrest in  Same patient in order to get some control information and we would like to correlate these changes with any distilled electrolytemia or  Exposure to medications which are known to cause rhythm changes and bradycardia  We would like to capture and analyze more cardiac arrest events  to look for further trends so we are actually working with Peddi Rescue multicenter group, which is the  Pediatric group which is looking at quality of resuscitation across the nation and even across the globe  And so we are looking at capturing this particular part of the data from all those centers  We would also like to look at the heart rate variability to predict any in-hospital cardiac arrest because again when we saw our our interval change as the one of the commonest and  the Most prominent change we believe that heart rate variability could be one of the important  Components which could help us predict how in-hospital cardiac arrest and we would like to create alert system in monitor based  On the intervals, but of course it will need some case control study and much larger patient population to look at Which we are already working on  That ends my talk. Thank you so much, and I'm happy to welcome questions. I  Have a I have a quick question How do you account for the association with the use of dexamethamidine in the cardiac arrest that you saw?  So it's a very good question. I think that is the reason we would like to get some control information in the same patient for meaning one hour and six hour prior to arrest whether  These some of these EKG interval changes, which we saw were they related to  medication or electrolyte imbalance  but at least from what data we have we know that  five minute prior to compressions were begun they had Particular EKG interval measurements and then as they started deteriorating  because of either hypoxemia and or hypotension or Combination there was significant change in the interval, so I think that's something very important  But yes, we would like to look at control data  Are there other questions?  Thank you  Our next speaker is Lin Liang from Virginia Commonwealth University He will be presenting on the effects of nlrp 3  nifazone blockade and post resuscitation cerebral function  Thank you Good afternoon ladies and gentlemen. I'm dr. Liang. I'm presenting this slide for communism he's the office of this study and  we all come from the wire Institute of emergency and critical research and  St. Joseph Memorial Hospital is my great honor to be here to present our study with you  So let's get stuff  and the study was performed at a wire Institute of emergency and critical care research and a protocol approved by the IACUC of Virginia Commonwealth University  We disclosed that we do not have any potential  conflicts of interest and Use of MCC 950 is investigation only no relevant financial relationships can exist  According to our variety of studies The sudden cardiac arrest is still one of the leading cause of death and remains a major public health issue  Despite the major advance in medical science and techniques in the past decade the survival rate in the medical science and  Inpatients with cardiac arrest remains long and most of their knowledgeable functions are poor even after successful resuscitation  several gaps in our knowledge of Mechanism on cardiac arrest are in the way  Among them the global ischemia reperfusion injury of the brain between cardiac arrest and CPR is a significant contributor to post-cardiac arrest  Neurological dysfunction and also mobility and mortality of these patients  growing evidence suggests that Inflammatory response with overproductions of iron beta contributes to the cerebral ischemia reperfusion injury  Furthermore iron beta signaling is regulated by the nrp3 inflammasome  the nrp3 inflammasome is activated by assembling of  nrp3 ASC and caspase-1 Then the assembled complex cleave  protocytokin iron beta  IL-18 to the activated form These cytokines act as effectors leading to one type of cell death pyrosis  Studies have shown that the nrp3 inflammasome is activated after Regional cerebral ischemia reperfusion is solved and in turn exacerbate the ischemia reperfusion injury  However, there's no evidence regarding the role of nrp3 inflammasome blockade with mcc950 in the global ischemia reperfusion injury of the cardiac arrest and CPR  In this context, we sought to investigate the effects of the selective  nrp3 inflammasome inhibitor mcc950 on post resuscitation plasma r1 beta  cerebral microcirculation, brain edemia  24-hour survival rate and  Neurological functions in the rather model of cardiac arrest and CPR  After animal preparation 36 male ST rats were randomized into three groups  1 mcc950 group, 2 control group and 3 same group Each group was subdivided into a 6-hour non-survival group and a 24-hour survival group  Cardiac arrest and ventricular vibration was induced through a guide-wide  advance from the right jungle wing into the right ventricle After 6 minutes on 3dVF and 8 minutes CPR The rest in the mcc950 group received one dose of mcc  IP injections immediately after RASC  instead Vehicle injections with water  Stereo water was given in the control group  The rest in the same group underwent the same surgical  procedures with the same control group  procedures with WVF and CPR  In the non-survival group, the cerebral microcirculation was mentioned at around 6 hours  Then the rest was sacrificed and the brain was obtained for the brain water content measurement to assess  cerebral edemia Capillomere survival plot and neurological deficit score were used for evaluating the  neurological outcomes in survival RAS In addition, the plasma R1 beta was mentioned  for evaluating the systemic inflammatory response and NSE for representing the severity of brain injury using the ELISA method  according to manufacturer's instructions Here are what we found Figures when they are representative graphs of  Cerebral microcirculations in these three groups  From the top to the bottom is same mcc950 and control  and from the from the figure we can find that  The density of micro vessels in the control group  was significantly decreased after cataracts and CPR when compared to a cell when compared to a cell  And use of the mcc950 can preserve the density of micro vessels, which was similar with the same  In addition the quantitative index of micro circulation including the  perfused vessel density PVD and micro circulatory flow index MFI was found to decrease  After cataracts and CPR in the control group when compared to the same group  And mcc950 interference  Can restore the PVD and MFI to their normal level  And figure 2 here show that the brain water contain Sorry The brain water contained in the control group was increased significantly  After cataracts and CPI in the control group when compared to the same  Which indicate the brain edema at rough six hour  The good news is mcc950 can prevent the brain from edema  We also find that the NSC which indicate the severity of brain injury was decreased was increased  Significantly after cataracts and CPI in the control group both at rough six hours and 24 hours  We further address whether the protective  The mcc950 can inhibit the increase of NSC  We further address whether the protective role of mcc950 is through  the inhibition of nrp3 Inflammation we clarify our  hypothesis that the increase of ion beta The increase of ion beta after cataracts and CPI in the control group Both at the six across six hours and 24 hours Was blocked by mcc950  Furthermore the 24-hour survival rate after loss in the mcc950 group was significantly improved  All of the six rats in the mcc950 group survived and only one  Rats in the uncontrolled group survived at rough 24 hour  in addition the neurological damage score was also  Improved significantly in the control in this mcc950 group when compared to control  From the video we can see that the only survival rate in the control group  Was had poor neurological  performance and the rest in the mcc950 group Has much better neuro neurological outcome than overall performance  From the video we can see that you can take food and water by itself. Just like the rest in the same group  In conclusion selective inhibition of nrp3 inflammation with mcc950  Reduce systemic level of r1 beta preserve cerebral microcirculation  mitigates Cerebral edemia improves 24-hour survival rate and neurological functions in our rat model of cataracts and cpr  therefore Our research findings suggest that mcc950 may be a promising  therapeutic candidate for lessening Post-resuscitation cerebral ischemia reperfusion injury. That's all. Thanks for your listening and any questions  Thomas drabeck saffer center for resuscitation research at the university of pittsburgh  You reported systemic levels of il1 beta. Did you look at cerebral levels of? Il1 beta at probably different brain regions or were you focused on the systemic effects of the drug?  You mean we actually we uh, I said we mentioned the plasma our beta  Sorry, can you repeat the question again? He's asking about systemic inflammation parameters versus the brain  We only looked at wet dry weight ratio in the brain and only looked at systemic il1 beta  Actually, we did not I mentioned our beta in the brain  Thank you  Can you speak to future directions for this research  okay, as thanks for the advice and  we are working on our job to uh  the for the job for the working on the our beta Uh and also the nrp3 inflammation with mcc 950  we selected in the translation medicine for opinion we are focused on the  methods of giving the drug and also we are  We are studying the combination of uh mcc 950 with other drug uh to  Explode the effects of the of uh  Inflammatory response  Yeah, thank you, thank you, dr. Ling, thank you  Our next speaker is brandon michael henry from cincinnati children's he will be presenting outcomes of repeated runs  Of extracorporeal membrane oxygenation support in adults analysis of the elso registry  Good evening, and thank you for the opportunity to present our  Study results with you today. I have no disclosures. So i'll dive right in  cardiopulmonary recovery and readiness to decannulate from ecmo Is not objective or success guaranteed. So if a patient deteriorates post decannulation  A subsequent run of ecmo may be considered. However, repeated runs of ecmo have difficulties one of which for example, uh, recannulation  Outcomes of multiple runs of ecmo have been reported to have variable success in pediatric patients However data is limited in survival benefit in adults remains unclear  so We investigated survival rates in adult patients receiving multiple runs of ecmo during the same hospitalization  And we aim to identify which factors influence mortality and survival in order to enable for better patient selection in the future  We collected our data from the Extracorporeal Life Support Organization Registry, also known as ELSO. ELSO is a prospective collection of cases from institutions  around the world of ECMO runs. We took all adults greater than 18 years of age receiving two or more runs of ECMO during the same hospitalization for any support type.  We then compared outcomes and complication rates based on the type of support and then evaluated the factors influencing outcomes in multivariate logistic regression.  So here we have a flowchart that shows our study selection, our patient selection and patient identification. Of the 51,061 adult runs of ECMO in the registry  as of January 2019, 2,288 of those, or 4.5%, were part of multiple ECMO runs. That equated to 1,144 patients. 1,041 of those had exactly two runs  of ECMO during the same hospitalization. And 103 had three or more runs of ECMO during the same hospitalization. So here we see patient demographics  and characteristics broken down by survival with patients who died on the left and those who were discharged alive on the right. First thing you'll notice is that patients  who were discharged alive were a bit younger. They had a median age of 47.7 compared to those who died who were 54.8. That intrigued us, so we broke down the data into age groups.  You see that patients who were then 18 to 30 had a survival rate of 51.7%, and it dropped thereafter. So we can see that with increasing age, right, survival decreases.  And when you reach age 51 and above, survival was all the way down to 30.9%. And we'll come back to that when we get to the multivariate analysis.  When we looked at mode of ECMO support on the first run, we see that patients who received VV ECMO had the highest rate of survival at 52%, whereas patients  who received VA ECMO had much lower survival at 33%. There were no other differences in factors such as weight, sex, or hours on ECMO. So we'll jump into survival.  So here we have on the left is the number of runs that a patient received broken into two runs or three or more runs. The second column has the support type on the first run,  number of patients, survival to discharge for those patients. And all the way on the right, we have the ELSA registry survival to discharge,  which basically we can equate to a single run patient. So for a patient who received pulmonary support on the first run, regardless of what they received  on the second run, had a survival to discharge of 51.7, about a 7% difference from the ELSA registry data. In patients who underwent a first run of cardiac support,  it dropped a bit to about 33.7%. And a patient who received first run eCPR, the survival rate was 32%, which is surprising it was actually 3% higher  than what we consider the single run ELSA registry data. When we look at three runs, again, you'll notice that pulmonary patients who received pulmonary support  on the first run, regardless of what they received on their other runs, had a survival to discharge of 37.2%, which was the highest for that group.  As I dropped to 27.7, and 50, 15.4 for eCPR.  So here we have survival to discharge by decade of ECMO support. You can see that the number of patients on the bottom there increased from 27 in the 90s to 82  in the 2000s, and over 1,000 in the past decade. So that made up the majority of the cases. Much of that is probably attributed to the fact  that ECMO has become much more utilized in adult patients. Over the past decade, however, as you'll see that there was really no change in survival.  It went from 37% in the 90s to only 40.1% in the past decade. Okay, so here we'll break down survival data into a bit more detail.  Here we have survival to discharge for two ECMO runs by type of support on the first run and second run. So we have the first run column  and the second run column all the way on the right. So we can follow then like a sample patient. So a patient who went from pulmonary support  to pulmonary support on a second run had a survival to discharge of 55.9%. That's the highest rate of survival we have in the entire cohort of patients.  When a patient goes from pulmonary to cardiac you can see that it drops. So it goes down to 37.5% for a patient going from first-run pulmonary to second-run cardiac.  And same with ECPR, it drops again to 22.2. But consistently we saw throughout the cohorts that patients received a second run of pulmonary support  or a final run of pulmonary support when we get the three-run patients had the best survival. So if we look at cardiac patients, patients who had heart failure and went  from cardiac support to cardiac support again, they only had a survival rate of like 31%. However, patients who went under cardiac support  and then needed pulmonary support as a second run, had a better survival at 10% higher. And that's consistent as you see throughout the data set that pulmonary support  in the second run offers the best survival.  Here we see the same data, survival of the discharge for three or more ECMO runs by type of support on the first run and the last run.  So this is for the three-run patients, the 103. So it's a bit limited data set. But it's broken down in a similar way. So we have what they had on the first run  and then what they had on the last run regardless of what they had in between. So patients who had pulmonary support on the first run  and pulmonary support on the last run had the best survival at 44.4%. We see a similar trend when we get to cardiac patients.  The first-run cardiac group who went on to need a final run of pulmonary support having a 33.3% survival as compared to 27.6% for the cardiac-to-cardiac.  So next we want to know what factors we should look for in selecting candidates for multiple runs of ECMO. So here we have first-run variables predicting death on the final run.  So for first-run pulmonary support, we see that age is associated with mortality. It's a very small odds ratio. But when you break it down to the fact  that for every one-year increase in age is associated with a 3% increase in odds, mortality becomes a bit significant. An inotrope requirement was also associated with first-run.  Inotrope requirements associated with mortality on the final run. For ECPR, again, we notice the age trend. But hemorrhagic complications really stood out here  with an odds ratio of 116. So that was a pretty big factor associated with mortality. For first-run cardiac support, there was nothing other than age, which is, as you can see,  a trend throughout the first-run variables. And interestingly for us, there was no first-run cardiac or pulmonary support ECMO complication that was associated  with mortality on the final run in multivariate analysis. So here we have now final-run variables predicting death on the final run.  So these are factors or complications of the final run that then indeed produced mortality. We can see that for pulmonary support, again, we have the age factor coming in,  but also the metabolic complications, neurologic complications, pulmonary complications. For first-run cardiac support, we have the infectious metabolic complications  that come into play. And for the ECPR, we have, again, we can point out those hemorrhagic complications, endowing very bad fortune on those patients.  So in conclusion, adults who deteriorate post-decannulation and require an additional run for pulmonary support are the ideal candidates for multi-run ECMO.  Outcomes in patients requiring repeated cardiac or ECPR support runs, especially in older patients, are poor. No first-run pulmonary or cardiac support complication decreases odds  of final-run survival. So those we probably should not take into account when screening candidates for additional runs of ECMO. And we'd advise that more than two runs of ECMO  for non-pulmonary indications should be undertaken with caution, especially in the setting of cardiopulmonary resuscitation. Thank you, and I'm happy to take any questions.  I have one quick question. It looked like your neuromuscular blockade had a protective effect. Do you think that was because there was colinearity  with the pulmonary indication for ECMO? It's certainly a possibility. It's something that we think we have to look at a bit more.  So we're going to take the data set as it is now and then look at specific groups of patients. So we're going to take the pulmonary group and analyze them  from a separate cohort from the cardiac to cardiac group. Because the patients are heterogeneous. We can't really compare them exactly.  So hopefully that will deal with some of that colinearity like you noticed in that data set. Yeah, and one kind of technical question  with the data gathering was, so were all of the separate, like a VV and VA runs, temporally separate? Or were some of those reported as separate runs for like,  we started with VV and then added an ALIM or started with VA and then added a VLIM for north-southing? Are you asking in terms of? Like did they consider those two separate runs?  Or were all of these decannulation? No, they're all decannulation in a new run. So the question was, how did your referee change from VA to VV ECMO? Yeah, changes are noted.  If we go back to the slide, we have like a conversion and those are particular factors there. So those are noted. They're not considered to be part of the same.  We're under a multi-run. So this is a patient we definitely decannulated and then had to put back on ECMO. Thank you. Thank you. And our last speaker was also our first speaker.  Uptal Balala is going to now present on extracorporeal cardiopulmonary resuscitation in the pediatric cardiac population.  Once again, thank you for the invitation. Again, it's an honor to be here for STAR Research Award presentation. So we'll talk about eCPR in the pediatric cardiac population,  which is our analysis from the virtual pediatric system database. And again, thanks to my collaborators, Harvey Lassa, Ravi Thyagarajan, and Daniel Cuffey.  We have put in a lot of good efforts together and we have some good data here to share. I do not have any financial disclosure or relationship to report.  eCPR has been utilized as a successful rescue modality for failed conventional CPR after pediatric in-hospital cardiac arrest among children with congenital  and acquired heart disease for over 30 years. In North America, majority of eCPR occurs in cardiac ICU  Now let's look at eCPR utilization in cardiac ICUs. So again, this report from Jeffrey Alton and co-authors on epidemiology and outcomes of cardiac arrest  in pediatric cardiac ICUs showed that almost one-third of cardiac arrest deployed eCPR in the cardiac ICUs. And 38.6% survived to hospital discharge.  What about unit versus patient factors? So Harvey Lassa from Texas Children's Hospital and co-authors published the report from Get with the Guideline Registry on eCPR in pediatric  in-hospital cardiac arrest. And they showed that majority eCPR were in cardiac patients, 79%. But what was not reported and what is not known is,  was there any unit characteristic, cardiac ICU versus mixed or PICU, which were related to the outcomes. Also, Tia Raymond from Dallas, she reported  from National Registry of Cardiopulmonary Resuscitation on outcomes among neonates, infants, and children after eCPR. And 3.8% eCPR use was reported from the registry.  And there was a significantly improved survival after eCPR among cardiac patients as compared to non-cardiac patients.  So we have some existing literature which provides limited data on impact of both patient and ICU level characteristics on outcomes after eCPR in the pediatric cardiac population.  So additional studies are needed to stratify the heterogeneous cardiac population, that is cardiac surgical versus cardiac medical,  in order to fully understand the risk factors for survival.  So leveraging standardized cardiac and mixed pediatric ICU clinical data from virtual pediatric system, or VPS, we aim to understand the impact of patient  and hospital level characteristics on outcomes of eCPR in pediatric cardiac surgical and cardiac medical population. So we hypothesize that ICU type, that is CICU versus mixed  or PICU, is associated with eCPR survival and favorable neurologic outcomes of medical and surgical cardiac patients resuscitated with eCPR in the VPS database.  Our inclusion criteria were ICU encounters which were reported in the VPS between January 1st, 2010 to 31st December 2018. And all the encounters which were submitted to VPS  in this time frame which had ECMO or cardiopulmonary bypass as a procedure reported within the two hours of initiation of CPR. We excluded trauma cases and those  in which ECMO occurred more than two hours after the initiation of CPR. Our primary outcome was survival to hospital discharge  and the secondary outcomes were favorable neurologic outcome, that is pediatric cerebral performance category, PCPC, of one, two, three, or no change from the admission baseline.  And this was based on the previous report from Robert Berg and co-authors. Characteristics and outcomes were compared by diagnosis using quantile regression, chi-square test,  and Fisher's exact test with a significant P value less than or equal to .05. Independent and multivariable mixed effect logistic regression accounting for correlation at patient  and hospital level were assessed for association between characteristics or cardiac groups and survival as well as favorable PCPC.  So we had more than a million ICU encounters reported in VPS between 2010 to 2018 amongst 7,334,756 patients. Of these, 12,931 cardiac arrest events were reported  in VPS amongst 11,853 patients. And of these, only 671 ECPR events were identified based on our inclusion criteria. So the ECPR rate within the VPS database during  that time frame was .07% only. Majority were cardiac surgical as compared to cardiac medical patients. And as you can see, majority of our patients were less than one year age.  And the children comprised 15% of patients and adolescent only 6% of patients. There were 52% patients which were male. And the congenital heart disease was seen  in 84% of the patients. What were our outcomes? So survival to hospital discharge was reported in 51% of cases. And favorable neurologic outcome was reported in 48% of survivors.  Of course, the limitation we had was amongst 31 cases, the PCPC was missing.  So this is some demographic information and some outcome information. So median weight was 4.2 kilo. Median CPR duration prior to ECMO was 45 minute  which is pretty similar to what has been reported by Harvey Lassa and co-authors previously. Median ECMO duration was 90.7 hours.  Median mechanical ventilation duration was 13.8 days. And median ICU length of stay was 21.2 days. So this is a comparative table between the patients  who are managed in cardiac ICU versus those who are managed in mixed PICU. As you can see, there were no significant difference with patient level characteristics.  That is weight, age, gender, race amongst the two groups. As far as the CPR duration prior to ECMO, the patients who are managed in cardiac ICU had significantly longer CPR  duration before going on ECMO as compared to those who are managed in mixed or PICU. And then the other characteristics such as ECMO duration, mechanical ventilator days,  and physical length of stay were not significantly different between the patients who are managed in cardiac ICU versus mixed ICU. Similarly, the survival  and favorable neurologic outcome were not significantly different between the two groups. When we look at the survivors versus non-survivors,  as you can see, the patient level characteristics, except the race, the weight, age, gender did not have any significant difference between the two groups.  The white race had better survival as compared to other races. Looking at the ICU level characteristics, so again, as we can see, cardiac surgical patients had better survival  as compared to cardiac medical patients. But the other ICU characteristics such as ICU type, ICU bed strength, academic status,  and whether the procedure was done weekend versus weekdays, and the CPR duration prior to ECMO were not significantly different between the two groups.  When we look at the favorable neurologic outcome, so we can see that, again, white race was associated with favorable neurologic outcome,  but the other patient characteristics did not have any impact on the neurologic outcome. When we look at the ICU characteristics, again,  as we can see that the cardiac surgical patients had favorable neurologic outcome as compared to cardiac medical patients,  and those patients who had ECPR done during the weekdays had better neurologic outcome as compared to those who had ECPR done during the weekends.  And the CPR duration was also significantly better in those who had favorable neurologic outcome. Multi-variable logistic regression showed  that survival to hospital discharge was significantly associated with illness category, cardiac surgical versus cardiac medical, while the ICU type and ICU bed capacity were not.  So the surgical cardiac patients were more likely to survive to hospital discharge compared to medical cardiac patients. White race and ECPR timing non-weekend were only factors  significantly associated with favorable neurologic outcome, and you can see the odds ratio for the two. So to summarize, survival to discharge was not affected  by age, race, gender, ICU bed capacity, ECPR timing, and academic status. Favorable neurologic outcome also was not affected by age, race, gender, illness category,  ICU type, and ICU bed strength. Patient level factors potentially outweigh the organizational factors. Of course, we had some limitations here.  So again, this was the study, the report based on the large database with inherent limitations. The way we defined ECPR cohort could also potentially challenge  the true ECPR population, and we did not have information on CPR quality, post-resuscitation care, or complications. So we conclude that the overall incidence  of ECPR among critically ill children with cardiac disease in VPS database is low, with significant variability in utilization across ICUs of varying size,  type, and academic standing. Patient level characteristics, surgical were more than medical, impact survival to hospital discharge and neurologic outcome after ECPR more  than the ICU type characteristics. Thank you. Thank you. Thank you for the presentation. A quick question, what was the cause of death of the patients  who did not make it out of the hospital? Do you analyze what did they die of? That's a good question. We don't have that granular data, but we know  that majority are related to neurologic, meaning brain death. So. Is it the complication of the ECPR itself or post-ECLS management? One second. So I might have that slide.  No, I don't have that supplemental slide, but a significant proportion of patients who died had the PCVC category of six, meaning brain death.  So again, we know that because of the way CPR is delivered and how the ECMO is deployed, they are at higher risk of neurologic injury, and one of the commonest cause of death  in these patient population is brain death. We have the data, so we should be able to look at it more granularly and provide that information. Thank you. Good question. Thank you.  I have a couple of questions, but it might just be one. You might be able to answer it in one part. Why is or why was the rate of ECPR utilization so low  and what are the barriers to utilization? It's a very good question. So I think you have to understand that VPS database is from all predominantly from the mixed  or PICUs as compared to the large cardiac ICUs. And so some of it might be related to the type of database we have utilized to capture the information.  But honestly, this is the first report where we have actually looked at all different types of ICUs. Majority of the literature is from the cardiac ICU  or the patients who had cardiac disease. So we believe that the low rate of ECPR could be also related to the database from where we have captured the information.  And in general, in pediatric, ECPR is still evolving, especially in the in-hospital cardiac arrest setting.

Video Summary

In this presentation, the speaker discusses the use of echocardiograms to predict cardiac arrest in hospitalized children. This is based on a study conducted by the speaker and their team. The study aimed to determine if there were specific pre-arrest electrocardiographic (EKG) changes that could be used to predict cardiac arrest in children. The study analyzed EKG data from pediatric in-hospital cardiac arrest cases and found that certain EKG changes, such as prolongation of the RR interval, were common prior to arrest. The study also found that 88% of patients had return of spontaneous circulation and survival to ICU discharge. However, it was noted that 27% of patients had hypokalemia and 8.1% had hypocalcemia prior to the event. It was also found that almost half of the patients were exposed to dexmedetomidine within 24 hours prior to the event. The speaker concluded that certain EKG changes could be used to predict in-hospital cardiac arrest in children and suggested further research to evaluate EKG intervals at different time points and to correlate these changes with electrolyte imbalances and exposure to medications. Additionally, the speaker mentioned the potential use of heart rate variability to predict in-hospital cardiac arrest.

Asset Subtitle

Resuscitation, Procedures, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Pre-Arrest Electrocardiographic Changes: Could They Predict Cardiac Arrest in Hospitalized Children?

Utpal S. Bhalala

Effects of NLRP3 Inflammasome Blockade on Post-Resuscitation Cerebral Function

Lin Liang

Outcomes of Repeated Extracorporeal Membrane Oxygenation in Adults: Analysis of the ELSO Registry

Brandon Michael Henry

ECPR in the Pediatric Cardiac Population: Analysis From the Virtual Pediatric System Database

Utpal S. Bhalala

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Area Procedures

Knowledge Level Advanced

Learning Pathway Skills and Procedures

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Cardiac Arrest

Tag Extracorporeal Membrane Oxygenation ECMO

Year 2020

Keywords

echocardiograms

predict cardiac arrest

hospitalized children

EKG changes

hypokalemia

hypocalcemia

dexmedetomidine exposure

heart rate variability

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