Association Between Time to Defibrillation and Survival in Pediatric In-Hospital Cardiac Arrest With a First Documented Shockable Rhythm | Cardiology | JAMA Network Open | JAMA Network
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    2 Comments for this article
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    Time to shock
    Frederick Rivara, MD, MPH | University of Washington
    Unlike in hospital cardiac arrest in adults, and data on pediatric OUT of hospital cardiac arrest, time to first defibrillation in children with IHCA and a shockable rhythm was not associated with survival to discharge. While these results are not easily explained, we clearly need to study this in large samples to try to understand what is going on and how to improve survival in these children.
    CONFLICT OF INTEREST: Editor in chief, JAMA Network Open
    Garbage In, Garbage Out
    John Stewart, RN, MA | None
    This article presents the finding that time to defibrillation is not inversely related to survival in in-hospital pediatric cardiac arrests with a presenting shockable rhythm, despite the well-recognized relationship in other settings. Such a conclusion calls for strong supportive evidence. This study falls short of that.

    The fundamental problem is the inaccurate underlying data. The Get With the Guidelines- Resuscitation registry has for decades reported without qualification inaccurate time-interval data from in-hospital resuscitation attempts, most prominently median times to first defibrillation of 1 minute for both adult and pediatric arrest. Clear indications of this inaccuracy include a study with
    the same first author as the present study (Reference 22), but evidence is available to anyone with experience of in-hospital resuscitation attempts, by simply reflecting on their own experience.

    Figure 2 shows that almost 45% of first shocks occurred at 0 minutes. Even granting the authors’ unsupported hypothesis that 0 minutes really represents 0-59 seconds, anything close to the reported result is impossible. With inconsistent and sometimes haphazard data collection using different methods across many facilities, the reported time-interval data are unreliable. To their credit, the authors acknowledge possible problems with the time data in the Limitations section, but that should be more than an afterthought: the poor quality of the data very likely invalidates the study’s conclusion.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Pediatrics
    September 21, 2018

    Association Between Time to Defibrillation and Survival in Pediatric In-Hospital Cardiac Arrest With a First Documented Shockable Rhythm

    Author Affiliations
    • 1Division of Health Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 2Department of Anesthesiology & Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 3Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
    • 4Department of Pediatric Cardiology and Pediatric Critical Care, Medical City Children’s Hospital, Dallas, Texas
    • 5Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
    • 6Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City
    • 7Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania, Philadelphia
    • 8Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 9Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 10Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
    JAMA Netw Open. 2018;1(5):e182643. doi:10.1001/jamanetworkopen.2018.2643
    Key Points español 中文 (chinese)

    Question  In children who have an in-hospital cardiac arrest with a first documented shockable rhythm, is time to first defibrillation attempt associated with survival to hospital discharge?

    Findings  In a cohort study from the Get With The Guidelines–Resuscitation national registry of 477 pediatric patients who experienced in-hospital cardiac arrest, time to first defibrillation attempt was not associated with survival. Time to first defibrillation was also not associated with return of circulation, 24-hour survival, or favorable neurologic outcome.

    Meaning  In contrast to published adult in-hospital cardiac arrest and pediatric out-of-hospital cardiac arrest data, there was no significant association between time to first defibrillation attempt in pediatric in-hospital cardiac arrests with first documented shockable rhythm and survival to hospital discharge.

    Abstract

    Importance  Delayed defibrillation (>2 minutes) in adult in-hospital cardiac arrest (IHCA) is associated with worse outcomes. Little is known about the timing and outcomes of defibrillation in pediatric IHCA.

    Objective  To determine whether time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm is associated with survival to hospital discharge.

    Design, Setting, and Participants  In this cohort study, data were obtained from the Get With The Guidelines–Resuscitation national registry between January 1, 2000, and December 31, 2015, and analyses were completed by October 1, 2017. Participants were pediatric patients younger than 18 years with an IHCA and a first documented rhythm of pulseless ventricular tachycardia or ventricular fibrillation and at least 1 defibrillation attempt.

    Exposures  Time between loss of pulse and first defibrillation attempt.

    Main Outcomes and Measures  The primary outcome was survival to hospital discharge. Secondary outcomes were return of circulation, 24-hour survival, and favorable neurologic outcome at hospital discharge.

    Results  Among 477 patients with a pulseless shockable rhythm (median [interquartile range] age, 4 years [3 months to 14 years]; 285 [60%] male), 338 (71%) had a first defibrillation attempt at 2 minutes or less after pulselessness. Children were less likely to be shocked in 2 minutes or less for ward vs intensive care unit IHCAs (48% [11 of 23] vs 72% [268 of 371]; P = .01]). Thirty-eight percent (179 patients) survived to hospital discharge. The median (interquartile range) reported time to first defibrillation attempt was 1 minute (0-3 minutes) in both survivors and nonsurvivors. Time to first defibrillation attempt was not associated with survival in unadjusted analysis (risk ratio [RR] per minute increase, 0.96; 95% CI, 0.92-1.01; P = .15) or adjusted analysis (RR, 0.99; 95% CI, 0.94-1.06; P = .86). There was no difference in survival between those with a first defibrillation attempt in 2 minutes or less vs more than 2 minutes in unadjusted analysis (132 of 338 [39%] vs 47 of 139 [34%]; RR, 0.87; 95% CI, 0.66-1.13; P = .29) or multivariable analysis (RR, 0.99; 95% CI, 0.75-1.30; P = .93). Time to first defibrillation attempt was also not associated with secondary outcome measures.

    Conclusions and Relevance  In contrast to published adult IHCA and pediatric out-of-hospital cardiac arrest data, no significant association was observed between time to first defibrillation attempt in pediatric IHCA with a first documented shockable rhythm and survival to hospital discharge.

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