OBJECTIVES:: Estrogen and progesterone improve neurologic outcomes in experimental models of cardiac arrest and stroke. Our objective was to determine whether women of child-bearing age are more likely than men to survive to hospital discharge after in-hospital cardiac arrest. DESIGN:: Prospective, observational study. SETTING:: Five hundred nineteen hospitals in the National Registry of Cardiopulmonary Resuscitation database. PATIENTS:: Patients included 95,852 men and women 15-44 yrs and 56 yrs or older with pulseless cardiac arrests from January 1, 2000 through July 31, 2008. MEASUREMENTS AND MAIN RESULTS:: Patients were stratified a priori by gender and age groups (15-44 yrs and >/=56 yrs). Fixed-effects regression conditioning in hospital was used to examine the relationship between age, gender, and survival outcomes. The unadjusted survival to discharge rate for younger women of child-bearing age (15-44 yrs) was 19%(940/4887) vs. 17%(1203/7025) for younger men (p =.013). The adjusted hospital discharge difference between these younger women and men was 2.8%(95% confidence interval, 1.0% to 4.6%; p =.002), and these younger women also had a 2.6%(95% confidence interval, 0.9% to 4.3%; p =.002) absolute increase in favorable neurologic outcome. For older women compared with men (>/=56 yrs), there were no demonstrable differences in discharge rates (18% vs. 18%; adjusted difference,-0.1%; 95% confidence interval,-0.9% to 0.6%; p =.68) or favorable neurologic outcome (14% vs. 14%; adjusted difference,-0.1%; 95% confidence interval,-0.7% to 0.5%; p =.74). CONCLUSIONS:: Women of child-bearing age were more likely than comparably aged men to survive to hospital discharge after in-hospital cardiac arrest, even after controlling for etiology of arrest and other important variables.

BACKGROUND: The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. We assessed the effect of CPR (conventional with rescue breathing or chest compression only) by bystanders on outcomes after out-of-hospital cardiac arrests in children. METHODS: In a nationwide, prospective, population-based, observational study, we enrolled 5170 children aged 17 years and younger who had an out-of-hospital cardiac arrest from Jan 1, 2005, to Dec 31, 2007. Data collected included age, cause, and presence and type of CPR by bystander. The primary endpoint was favourable neurological outcome 1 month after an out-of-hospital cardiac arrest, defined as Glasgow-Pittsburgh cerebral performance category 1 or 2. FINDINGS: 3675 (71%) children had arrests of non-cardiac causes and 1495 (29%) cardiac causes. 1551 (30%) received conventional CPR and 888 (17%) compression-only CPR. Data for type of CPR by bystander were not available for 12 children. Children who were given CPR by a bystander had a significantly higher rate of favourable neurological outcome than did those not given CPR (4.5%[110/2439] vs 1.9%[53/2719]; adjusted odds ratio [OR] 2.59, 95% CI 1.81-3.71). In children aged 1-17 years who had arrests of non-cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (5.1%[51/1004] vs 1.5%[20/1293]; OR 4.17, 2.37-7.32). However, conventional CPR produced more favourable neurological outcome than did compression-only CPR (7.2%[45/624] vs 1.6%[six of 380]; OR 5.54, 2.52-16.99). In children aged 1-17 years who had arrests of cardiac causes, favourable neurological outcome was more common after bystander CPR than no CPR (9.5%[42/440] vs 4.1%[14/339]; OR 2.21, 1.08-4.54), and did not differ between conventional and compression-only CPR (9.9%[28/282] vs 8.9%[14/158]; OR 1.20, 0.55-2.66). In infants (aged <1 year), outcomes were uniformly poor (1.7%[36/2082] with favourable neurological outcome). INTERPRETATION: For children who have out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander is the preferable approach to resuscitation. For arrests of cardiac causes, either conventional or compression-only CPR is similarly effective. FUNDING: Fire and Disaster Management Agency and the Ministry of Education, Culture, Sports, Science and Technology (Japan).

Objective: We hypothesized that childhood obesity would be associated with decreased likelihood of survival to hospital discharge after in-hospital, pediatric cardiopulmonary resuscitation (CPR). Methods: We reviewed 1477 consecutive, pediatric, CPR index events (defined as the first CPR event during a hospitalization in that facility for a patient <18 years of age) reported to the American Heart Association National Registry of Cardiopulmonary Resuscitation between January 2000 and July 2004. The primary outcome was survival to hospital discharge. A total of 1268 index subjects (86%) with complete registry data were included for analysis. Children were classified as obese (>/=95th weight-for-length percentile if <2 years of age or >/=95th BMI-for-age percentile if >/=2 years of age) or underweight (<5th weight-for-length percentile if <2 years of age or <5th BMI-for-age percentile if >/=2 years of age), with adjustment for gender. Results: Obesity was noted for 213 (17%) of 1268 subjects and underweight for 571 (45%) of 1268 subjects. Obesity was more likely to be associated with male gender, noncardiac medical illness, and cancer and inversely associated with heart failure. Underweight was more likely to be associated with male gender, cardiac surgery, and prematurity and inversely associated with age and cancer. Self-reported, process-of-care, CPR quality was generally worse for obese children. With adjustment for important potential confounding factors, obesity was independently associated with worse odds of event survival (adjusted odds ratio: 0.58 [95% confidence interval: 0.35-0.76]) and survival to hospital discharge (adjusted odds ratio: 0.62 [95% confidence interval: 0.38-0.93]) after in-hospital, pediatric CPR. Underweight was not associated with worse outcomes. Conclusions: Childhood obesity is associated with a lower rate of survival to hospital discharge after in-hospital, pediatric CPR.

OBJECTIVE:: Complete recoil of the chest wall between chest compressions during cardiopulmonary resuscitation is recommended, because incomplete chest wall recoil from leaning may decrease venous return and thereby decrease blood flow. We evaluated the hemodynamic effect of 10% or 20% lean during piglet cardiopulmonary resuscitation. DESIGN:: Prospective, sequential, controlled experimental animal investigation. SETTING:: University research laboratory. SUBJECTS:: Domestic piglets. INTERVENTIONS:: After induction of ventricular fibrillation, cardiopulmonary resuscitation was provided to ten piglets (10.7 +/- 1.2 kg) for 18 mins as six 3-min epochs with no lean, 10% lean, or 20% lean to maintain aortic systolic pressure of 80-90 mm Hg. Because the mean force to attain 80-90 mm Hg was 18 kg in preliminary studies, the equivalent of 10% and 20% lean was provided by use of 1.8- and 3.6-kg weights on the chest. MEASUREMENTS AND MAIN RESULTS:: Using a linear mixed-effect regression model to control for changes in cardiopulmonary resuscitation hemodynamics over time, mean right atrial diastolic pressure was 9 +/- 0.6 mm Hg with no lean, 10 +/- 0.3 mm Hg with 10% lean (p <.01), and 13 +/- 0.3 mm Hg with 20% lean (p <.01), resulting in decreased coronary perfusion pressure with leaning. Microsphere-determined cardiac index and left ventricular myocardial blood flow were lower with 10% and 20% leaning throughout the 18 mins of cardiopulmonary resuscitation. Mean cardiac index decreased from 1.9 +/- 0.2 L . M . min with no leaning to 1.6 +/- 0.1 L . M . min with 10% leaning, and 1.4 +/- 0.2 L . M . min with 20% leaning (p <.05). The myocardial blood flow decreased from 39 +/- 7 mL . min . 100 g with no lean to 30 +/- 6 mL . min . 100 g with 10% leaning and 26 +/- 6 mL . min . 100 g with 20% leaning (p <.05). CONCLUSIONS:: Leaning of 10% to 20%(i.e., 1.8-3.6 kg) during cardiopulmonary resuscitation substantially decreased coronary perfusion pressure, cardiac index, and myocardial blood flow.

Objective: The objective of this study was to assess whether pediatric inpatients who receive cardiopulmonary resuscitation (CPR) for bradycardia with poor perfusion are more likely to survive to hospital discharge than pediatric inpatients who receive CPR for pulseless arrest (asystole/pulseless electrical activity [PEA]), after controlling for confounding characteristics. Methods: A prospective cohort from the National Registry of Cardiopulmonary Resuscitation was enrolled between January 4, 2000, and February 23, 2008. Patients who were younger than 18 years and had an in-hospital event that required chest compressions for >2 minutes were eligible. Patients were divided into 2 groups on the basis of initial rhythm and pulse state: bradycardia/poor perfusion and asystole/PEA. Patient characteristics, event characteristics, and clinical characteristics were analyzed as possible confounders. Univariate analysis between bradycardia and asystole/PEA patient groups was performed. Multivariable logistic regression was used to determine whether an initial state of bradycardia/poor perfusion was independently associated with survival to discharge. Results: A total of 6288 patients who were younger than 18 years were reported; 3342 met all inclusion criteria. A total of 1853 (55%) patients received chest compressions for bradycardia/poor perfusion compared with 1489 (45%) for asystole/PEA. Overall, 755 (40.7%) of 1353 patients with bradycardia survived to hospital discharge, compared with 365 (24.5%) of 1489 patients with asystole/PEA. After controlling for known confounders, CPR for bradycardia with poor perfusion was associated with increased survival to hospital discharge. Conclusions: Pediatric inpatients with chest compressions initiated for bradycardia and poor perfusion before onset of pulselessness were more likely to survive to discharge than pediatric inpatients with chest compressions initiated for asystole or PEA.

BACKGROUND: High-fidelity manikins have been shown to be useful in teaching appropriate cardiopulmonary resuscitation (CPR) techniques. Similarity of manikin chest compression characteristics to real children is desirable. Little data exists on thorax stiffness in infants and children to guide manikin construction. OBJECTIVE: To determine a 'consensus clinical-expert assessment' of the pediatric chest stiffness for two specific age groups-infants and 5-year-olds. METHODS: Four manikins in each of two sizes (5-year child, 6-month infant) were identically constructed, except for thorax downstroke spring stiffness. Health care providers with pediatric CPR experience provided chest compressions to each manikin in random order, masked to thoracic stiffness. Each health care provider was instructed to identify the manikin with downstroke thoracic stiffness most similar to children on whom they have performed chest compressions. Duplicate assessment of a randomly selected, previously assessed manikin was performed to assess health care provider consistency using the kappa statistic. Subject inter-rater agreement on which manikin best approximated a child of that age was assessed by calculating the percentage of subjects who identified that manikin as the best approximation of an actual child. RESULTS: A convenience sample of 63 international experts was obtained: 52 from Critical Care, 3 from Emergency Medicine, 4 from Pediatrics, and 4 from other specialties. There were 6 and 8 experts whose assessments were inconsistent for the infant manikins and child manikins, respectively. Approximately half of the subjects agreed on a single manikin as the best approximation of the human for both the infant (46%) and child manikins (43%). Excluding assessments of stiffness "out of range", the percentage of experts who agreed on a single manikin as the best approximation for the human increased to approximately 90% for each manikin size. CONCLUSION: Experienced health care providers consistently identified and agreed on the manikin thorax stiffness which they felt best approximated downstroke chest compression stiffness of children and infants. Expert opinion can be used to create manikins with realistic spring stiffness for CPR training. Further study is needed to evaluate whether enhanced manikin biofidelity will improve CPR performance.

PURPOSE: The aim of the study is to test the effect of age and preextracorporeal membrane oxygenation (pre-ECMO) days of ventilation on ECMO survival in the pediatric population. METHODS: Retrospective analysis of noncardiac, pediatric (age >30 days) ECMO patients for the period January 1984 to June 2006. Pre-ECMO demographic, ventilatory, and lung injury severity variables were modeled with stepwise logistic regression to estimate survival probabilities associated with pre-ECMO ventilation duration and patient age. Patients were excluded from review for the following: pre-ECMO cardiac arrest, pre-ECMO ventilation of more than 30 days (chronic), or multiple runs on ECMO. RESULTS: For the period of review, 2550 patients met inclusion/exclusion criteria. The population had a mean age of 3.6 +/- 5.1 years (median age, 1 year). The mean pre-ECMO days of ventilation were 5.2 +/- 4.9 (median, 4 days). The overall survival probability was 58.6%. The mean oxygen index and Pao(2)/Fio(2) ratio were 62.2 +/- 48.2 and 95.5 +/- 48.2, respectively. The population overall demonstrated a statistically significant, exponential decline in survival as pre-ECMO days of ventilation increased (P <.05). For each additional year of age, survival decreased by an average of 2.5%. For each additional day of pre-ECMO ventilation, survival decreased by an average of 2.9%. Younger ages were generally associated with higher survival probabilities at each ventilation day. CONCLUSIONS: In the pediatric population, survival decreases significantly as pre-ECMO ventilator days increase. Survival is also inversely related to patient age. Thus, patient age and duration of ventilation should be considered when evaluating suitability for ECMO.

PURPOSE OF REVIEW: To summarize recent advances in pediatric cardiopulmonary arrest prevention, resuscitation and postresuscitation management. RECENT FINDINGS: Pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. Data in the 21st century indicate that more than 25% of children treated for in-hospital cardiac arrests survive to hospital discharge and more than 10% of children older than 1 year treated for out-of-hospital cardiac arrests survive to hospital discharge. These data establish that children are more likely to survive to hospital discharge than adults after both in-hospital and out-of-hospital cardiac arrests. Before arrest, exciting new studies demonstrate that the implementation of in-hospital pediatric medical emergency teams is associated with significant decreases in cardiac arrest incidence and overall pediatric hospital mortality. During arrest, ventricular fibrillation or ventricular tachycardia, once thought to be rare in children, occurs during 25% of inhospital pediatric cardiac arrests and at least 7% of out-of-hospital pediatric cardiac arrests. Survival to hospital discharge is much more likely after arrests with a first documented rhythm of ventricular fibrillation or ventricular tachycardia than after pulseless electric activity and asystole. However, ventricular fibrillation or ventricular tachycardia is not always a favorable rhythm, as survival to discharge is much less likely when ventricular fibrillation or ventricular tachycardia occurs during resuscitation from an arrest with the first documented rhythm of pulseless electric activity or asystole. Further, extracorporeal membrane oxygenation cardiopulmonary resuscitation appears promising under special resuscitation circumstances to improve outcome from highly selected in-hospital pediatric cardiac arrest victims. Further, postresuscitation interventions such as goal-directed therapies and therapeutic hypothermia have been demonstrated in adults and infants to improve outcome for selected cardiac arrest victims and are promising candidate targets for study in children. SUMMARY: Pediatric cardiac arrest is not a futile condition; many children are successfully resuscitated each year. The implementation of new prearrest, intraarrest and postresuscitative therapies has the potential to further improve survival rates following pediatric cardiac arrest.