CPR Intervention Failed to Improve Survival in Kids With Cardiac Arrest

An intervention involving physiologically focused CPR training in pediatric intensive care units (PICUs) failed to significantly improve survival outcomes, a randomized trial found.

Among 18 PICUs and over 1,000 patients who experienced an in-hospital cardiac arrest, there was no significant difference in survival to discharge with favorable neurologic outcomes after CPR between the intervention and control groups (53.8% vs 52.4%; adjusted OR [aOR] 1.08, 95% CI 0.76-1.53), reported Robert Sutton, MD, MSCE, of the Children’s Hospital of Philadelphia, and colleagues from the Collaborative Pediatric Critical Care Research Network (CPCCRN).

This result was unchanged when looking only at patients who received CPR for at least 1 minute, for at least 5 minutes, and prior to COVID-19 restrictions, the researchers noted in JAMA.

In addition, there was no significant difference in survival to discharge between the groups (58% of the intervention group vs 56.8% of the control group; aOR 1.03, 95% CI 0.73-1.47).

​​”Although observational studies have demonstrated improved outcomes when clinicians report using physiologic data to guide resuscitation, to our knowledge, no multicenter randomized clinical trials assessing the effectiveness of this approach in pediatric ICUs have been previously performed,” they wrote.

The intervention consisted of two parts: point-of-care CPR training on a manikin and monthly hour-long debriefings that focused on physiological factors in cardiac arrest. For the intervention, each ICU was expected to conduct 48 CPR trainings a month.

“There are several possible explanations for failure of this intervention to improve patient survival to hospital discharge with a favorable neurologic outcome,” Sutton and team noted. They pointed out that this outcome occurred in over 50% of patients even in the control group, which is higher than what was previously reported in other large-scale studies.

“This may have resulted in limited ability to detect a significant improvement in outcomes, with a ceiling effect primarily due to the control group having incorporated physiologic-targeted CPR and postarrest care from previous CPCCRN physiologically focused in-hospital cardiac arrest studies,” they added.

According to a 2019 study, less than half of children who suffer in-hospital cardiac arrest survive, and while that rate has improved since 2000, it plateaued in 2010. The intervention was designed based on American Heart Association CPR guidelines, “which have historically focused on CPR mechanics such as compression depth and rate,” but “currently highlight resuscitation training to intra-arrest and postarrest physiologic targets as a strategy to improve outcomes,” Sutton and team wrote.

In a post-hoc analysis, the researchers found that systolic hypotension was less likely to occur in the 24 hours after return of circulation in the intervention group compared with the control group (62.1% vs 71.4%; aOR 0.59, 95% CI 0.37-0.93, P=0.02).

The intervention ran from October 2016 to March 2021 and was of a hybrid design: three ICUs remained in the intervention group, three in the control group, and 12 ICUs flip-flopped every 7 months between the groups. Due to COVID-19, the CPR training programs were paused, but monthly debriefings continued virtually.

Of 1,276 patients (median age 0.6 years, 44% girls), 1,074 index CPR events were included in the primary analysis. Children were excluded if they had an out-of-hospital cardiac arrest or if they could not undergo aggressive ICU therapies.

The primary outcome of survival to hospital discharge with favorable neurologic outcomes was measured by the Pediatric Cerebral Performance Category, with scores ranging from 1 (normal) to 6 (death).

Of note, the PICUs were allowed to undergo other resuscitation quality improvement trials as long as they were not identical to this intervention.

Sutton and team noted that the enrolled sites were academic PICUs “with an interest in physiologic resuscitation that may limit generalizability to other nonacademic pediatric ICUs or those with different staffing patterns or incidence of CPR.”

They also acknowledged that the study was underpowered to detect a potentially important difference in outcomes between the groups, given the wide confidence intervals.