Better CPR for Non-Shockable Arrest; PICU Transfusions; PTSD After Child's ICU Stay

SAN FRANCISCO -- CPR with a device that raises the head to improve blood circulation had better-than-expected neurologically intact survival for out-of-hospital cardiac arrest (OHCA) in patients for whom automated external defibrillators (AEDs) won't work, researchers reported.

The EleGARD system for gradual head- and torso-up positioning with the Lucas automated chest compression and decompression device yielded survival with good neurologic outcomes for non-shockable patients in 3.09-fold more cases than standard CPR alone (16 of 380 vs 26 of 1,852).

After matching for age, sex, bystander CPR, witnessed arrest, time elapsed from the 911 call to EMS CPR, and other factors, the difference was 3.87-fold.

"Neuroprotective CPR can be viewed as the AED equivalent for non-shockable OHCA cases, but even better," reported Paul E. Pepe, MD, MPH, adjunct at of the University of Texas Health Science Center in Houston, during a presentation at the Society of Critical Care Medicine (SCCM) Critical Care Congress.

The group had previously reported on good outcomes in OHCA overall, and these findings extend them to the large proportion of cases with historically poor outcomes due to pulseless or otherwise non-shockable heart rhythms.

For pulseless electrical activity patients, the automated system CPR had significant 2.33-fold higher odds of survival to hospital discharge (13% vs 6.2%) and significant 3.83-fold higher odds of survival neurologically intact (9.8% vs 2.8%).

The study was a propensity score-matched comparison of out-of-hospital patients presenting with asystole or pulseless electrical activity: 380 in a registry of five U.S. emergency medical systems using the equipment (St. John's County, Florida; Anoka County, Minnesota; Peoria, Illinois; Edina, Minnesota; and Lucas County, Ohio) from 2020 through 2021 against 1,852 patients in the ROC PRIMED and ResQ trials.

Earlier use of the heads-up application bundle was associated with better results. Median time to application of the device system was 8 minutes, and 80% of uses started within 16 minutes.

Despite the relatively small sample sizes, the "statistics are already compelling," Pepe said, especially as the comparator was in high-performing EMS systems participating in NIH-sponsored trials in which quality and outcomes were carefully tracked.

PICU Transfusion Thresholds

Using the guideline-recommended transfusion threshold of 7 g/dL, hemoglobin in the pediatric intensive care unit (PICU) was not associated with increased organ dysfunction, but was independently associated with survival to ICU discharge and lower ICU costs, according to a subanalysis of the ABC-PICU trial.

Hemodynamically stable children without cardiac disease who were transfused when their hemoglobin was under 7 g/dL versus at that threshold or above it were no more likely to have new or progressive multiple organ system dysfunction (relative risk 0.86, 95% CI 0.61-1.22, P=0.40), reported Katherine Steffen, MD, MHS, of Stanford University School of Medicine in Palo Alto, California, during the SCCM meeting and in Pediatric Critical Care Medicine.

The 7 g/dL hemoglobin threshold recommended by the TAXI guidelines for pediatric transfusions, based on the TRIPICU trial results, was not significantly associated with a difference in the mean number of total transfusions, risk of sepsis, acute respiratory distress syndrome, nosocomial infection, maximum degree of organ dysfunction, ICU mortality, or 28-day mortality.

However, patients in the guideline-compliant group had more ICU-free days (mean difference 1.73, P=0.003) and more ventilator-free days (mean difference 1.56, P=0.004), which reduced the estimated cost of PICU care by $32,963 per patient.

Fully 49% of the 687 children in the analysis were transfused at a threshold above the recommended hemoglobin threshold, "indicating a failure to adopt RCT [randomized controlled trial] evidence into practice and potentially transfusion in anticipation of need, rather than clinical assessment, even in research-oriented PICUs," the researchers noted. "Despite efforts to promote dissemination and implementation of the TAXI recommendations, the lack of uptake of the TRIPICU evidence published nearly a decade prior underscores the necessity of a formal, structured implementation approach to ensure integration of recommendations into clinical practice."

Parental PTSD After Child's ICU Stay

Some parents of critically ill children continued to have or even developed post-traumatic stress disorder (PTSD) more than a year after the admission, a study showed.

Of 175 parents assessed 18-30 months after their child's ICU stay, 12.5% met PTSD qualifications, which wasn't much less than the 14.8% rate of acute stress disorder when assessed at 3-9 months, reported Mekela Whyte-Nesfield, MD, of Children's National Hospital in Washington, D.C., speaking at a late-breaking SCCM session. The findings were also published in Pediatric Critical Care Medicine.

PTSD was independently predicted by parents having met criteria for acute stress disorder (OR 4.19, 95% CI 1.12-15.7), parents' history of a family member or themselves being admitted to the ICU (OR 6.51, 95% CI 1.43-29.6), and parents' concerns about their child's susceptibility to death after discharge (OR 1.58, 95% CI 1.19-2.09).

Parents who met criteria for PTSD at 18-30 months were more than nine times more likely to report that their household income had dropped after the discharge, suggesting a change in employment status.

Notably, 7% had PTSD at both the earlier and later time points, 7% had it at the initial assessment only, and 5% developed it after the initial assessment, although based on small numbers (8 to 11 persons per group).

The study enrolled a group of 265 parents (45% female) of 188 children who were surveyed after their child's ICU stay at a median 3 years of age. About half had pre-existing chronic medical illness and history of ICU stays.

Of the parents, 45% had a prior history of ICU admission or a close family member having been in the ICU, 20% had a history of major accident or disaster, and 14% had a history of assault or abuse.

Cases in which the child died were excluded because it's hard to distinguish grief from PTSD from the admission, Whyte-Nesfield said.

"Mitigating PICU-associated parental PTSD is an essential component of family-centered care and improving post-intensive care syndrome pediatrics; additional studies should examine targeted interventions," the group concluded.