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Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes*

Sutton, Robert M. MD, MSCE1; Reeder, Ron W. PhD2; Landis, William P. BSE1; Meert, Kathleen L. MD3; Yates, Andrew R. MD4; Morgan, Ryan W. MD, MTR1; Berger, John T. MD5; Newth, Christopher J. MD, FRACP6; Carcillo, Joseph A. MD7; McQuillen, Patrick S. MD8; Harrison, Rick E. MD9; Moler, Frank W. MD10; Pollack, Murray M. MD5,11; Carpenter, Todd C. MD12; Notterman, Daniel A. MD13; Holubkov, Richard PhD2; Dean, J. Michael MD2; Nadkarni, Vinay M. MD, MS1; Berg, Robert A. MD1; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN)

doi: 10.1097/CCM.0000000000003898
Pediatric Critical Care

Objectives: The objective of this study was to associate ventilation rates during in-hospital cardiopulmonary resuscitation with 1) arterial blood pressure during cardiopulmonary resuscitation and 2) survival outcomes.

Design: Prospective, multicenter observational study.

Setting: Pediatric and pediatric cardiac ICUs of the Collaborative Pediatric Critical Care Research Network.

Patients: Intubated children (≥ 37 wk gestation and < 19 yr old) who received at least 1 minute of cardiopulmonary resuscitation.

Interventions: None.

Measurements and Main Results: Arterial blood pressure and ventilation rate (breaths/min) were manually extracted from arterial line and capnogram waveforms. Guideline rate was defined as 10 ± 2 breaths/min; high ventilation rate as greater than or equal to 30 breaths/min in children less than 1 year old, and greater than or equal to 25 breaths/min in older children. The primary outcome was survival to hospital discharge. Regression models using Firth penalized likelihood assessed the association between ventilation rates and outcomes. Ventilation rates were available for 52 events (47 patients). More than half of patients (30/47; 64%) were less than 1 year old. Eighteen patients (38%) survived to discharge. Median event-level average ventilation rate was 29.8 breaths/min (interquartile range, 23.8–35.7). No event-level average ventilation rate was within guidelines; 30 events (58%) had high ventilation rates. The only significant association between ventilation rate and arterial blood pressure occurred in children 1 year old or older and was present for systolic blood pressure only (–17.8 mm Hg/10 breaths/min; 95% CI, –27.6 to –8.1; p < 0.01). High ventilation rates were associated with a higher odds of survival to discharge (odds ratio, 4.73; p = 0.029). This association was stable after individually controlling for location (adjusted odds ratio, 5.97; p = 0.022), initial rhythm (adjusted odds ratio, 3.87; p = 0.066), and time of day (adjusted odds ratio, 4.12; p = 0.049).

Conclusions: In this multicenter cohort, ventilation rates exceeding guidelines were common. Among the range of rates delivered, higher rates were associated with improved survival to hospital discharge.

1Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.

2Department of Pediatrics, University of Utah, Salt Lake City, UT.

3Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University, Detroit, MI.

4Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH.

5Department of Pediatrics, Children’s National Medical Center, Washington, DC.

6Department of Anesthesiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA.

7Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA.

8Department of Pediatrics, Benioff Children’s Hospital, University of California San Francisco, San Francisco, CA.

9Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA.

10Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI.

11Department of Pediatrics, Phoenix Children’s Hospital, Phoenix, AZ.

12Department of Pediatrics, Denver Children’s Hospital, University of Colorado, Denver, CO.

13Department of Molecular Biology, Princeton University, Princeton, NJ.

*See also p. 1672.

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Supported, in part, by the following cooperative agreements from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and Department of Health and Human Services: UG1HD050096, UG1HD049981, UG1HD049983, UG1HD063108, UG1HD083171, UG1HD083166, UG1HD083170, U10HD050012, U10HD063106, U10HD063114, and U01HD049934.

All authors received support for article research from the National Institutes of Health (NIH). Dr. Sutton, Dr. Reeder, Mr. Landis, Dr. Meert, Dr. Yates, Dr. Berger, Dr. Harrison, Dr. Moler, Dr. Pollack, Dr. Holubkov, and Dr. Berg’s institutions received funding from the NIH. Dr. Sutton received funding from Zoll Medical (speaking honoraria), and he disclosed that he is the Chair Elect of the Pediatric Research Task Force of the American Heart Association’s (AHA’s) Get with the Guidelines Resuscitation registry, a 2015 and 2018 Pediatric Advanced Life Support Guidelines Author, and a member of the AHA’s Emergency Cardiovascular Care Committee’s Pediatric Emphasis Group. He reports grant funding from the NIH. Dr. Berger’s institution also received funding from Association for Pediatric Pulmonary Hypertension and Actelion. Drs. Newth, Carcillo, McQuillen, Notterman, and Dean’s institutions received funding from the National Institute of Child Health and Human Development. Dr. Newth received funding from Philips Research North America. He reports consulting services for both Philips Research of North America and Medtronics. Dr. Moler reports NIH funding paid to his institution. Dr. Pollack reports grant funding from the NIH and the Department of Defense, collaborative projects with Cerner, and philanthropy from Mallinckrodt Pharmaceuticals. Dr. Holubkov received funding from Pfizer (DSMB member), MedImmune (DSMB), Physicians Committee for Responsible Medicine (Biostatistical Consulting), DURECT (Biostatistical Consulting), American Burn Association (DSMB), Armaron Bio (DSMB), and St. Jude Medical (Biostatistical Consulting).

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