First name
Robert
Middle name
A
Last name
Berg

Title

Guidance for Cardiopulmonary Resuscitation of Children With Suspected or Confirmed COVID-19.

Year of Publication

2022

Date Published

07/2022

ISSN Number

1098-4275

Abstract

This document aims to provide guidance to healthcare workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed COVID-19. It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care while providing strategies for reducing risk of transmission of SARS-CoV-2 to healthcare providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Due to the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures (AGPs). Thus, personal protective equipment (PPE) appropriate for AGPs (including N95 respirators or an equivalent) should be donned prior to resuscitation and high-efficiency particulate air (HEPA) filters should be utilized. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms except for specific attention to infection prevention and control. In summary, healthcare personnel should continue to reduce the risk of SARS-CoV-2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Healthcare organizations should ensure the availability and appropriate use of PPE. As delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

DOI

10.1542/peds.2021-056043

Alternate Title

Pediatrics

PMID

35818123

Title

Compression-Only Versus Rescue-Breathing Cardiopulmonary Resuscitation After Pediatric Out-of-Hospital Cardiac Arrest.

Year of Publication

2021

Number of Pages

1042-1052

Date Published

2021 Sep 07

ISSN Number

1558-3597

Abstract

<p><strong>BACKGROUND: </strong>There are conflicting data regarding the benefit of compression-only bystander cardiopulmonary resuscitation (CO-CPR) compared with CPR with rescue breathing (RB-CPR) after pediatric out-of-hospital cardiac arrest (OHCA).</p>

<p><strong>OBJECTIVES: </strong>This study sought to test the hypothesis that RB-CPR is associated with improved neurologically favorable survival compared with CO-CPR following pediatric OHCA, and to characterize age-stratified outcomes with CPR type compared with no bystander CPR (NO-CPR).</p>

<p><strong>METHODS: </strong>Analysis of the CARES registry (Cardiac Arrest Registry to Enhance Survival) for nontraumatic pediatric OHCAs (patients aged&nbsp;≤18 years) from 2013-2019 was performed. Age groups included infants (&lt;1 year), children (1 to 11 years), and adolescents (≥12 years). The primary outcome was neurologically favorable survival at hospital discharge.</p>

<p><strong>RESULTS: </strong>Of 13,060 pediatric OHCAs, 46.5% received bystander CPR. CO-CPR was the most common bystander CPR type. In the overall cohort, neurologically favorable survival was associated with RB-CPR (adjusted OR: 2.16; 95%&nbsp;CI: 1.78-2.62) and CO-CPR (adjusted OR: 1.61; 95%&nbsp;CI: 1.34-1.94) compared with NO-CPR. RB-CPR was associated with a higher odds of neurologically favorable survival compared with CO-CPR (adjusted OR: 1.36; 95%&nbsp;CI: 1.10-1.68). In age-stratified analysis, RB-CPR was associated with better neurologically favorable survival versus NO-CPR in all age groups. CO-CPR was associated with better neurologically favorable survival compared with NO-CPR in children and adolescents, but not in infants.</p>

<p><strong>CONCLUSIONS: </strong>CO-CPR was the most common type of bystander CPR in pediatric OHCA. RB-CPR was associated with better outcomes compared with CO-CPR. These results support present guidelines for RB-CPR as the preferred CPR modality for pediatric OHCA.</p>

DOI

10.1016/j.jacc.2021.06.042

Alternate Title

J Am Coll Cardiol

PMID

34474737

Title

Race/Ethnicity and Neighborhood Characteristics Are Associated With Bystander Cardiopulmonary Resuscitation in Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Study From CARES.

Year of Publication

2019

Number of Pages

e012637

Date Published

2019 Jul 16

ISSN Number

2047-9980

Abstract

<p>Background Whether racial and neighborhood characteristics are associated with bystander cardiopulmonary resuscitation ( BCPR ) in pediatric out-of-hospital cardiac arrest ( OHCA ) is unknown. Methods and Results An analysis was conducted of CARES (Cardiac Arrest Registry to Enhance Survival) for pediatric nontraumatic OHCA s from 2013 to 2017. An index (range, 0-4) was created for each arrest based on neighborhood characteristics associated with low BCPR (&gt;80% black; &gt;10% unemployment; &lt;80% high school; median income, &lt;$50&nbsp;000). The primary outcome was BCPR . BCPR occurred in 3399 of 7086 OHCA s (48%). Compared with white children, BCPR was less likely in other races/ethnicities (black: adjusted odds ratio [ aOR ], 0.59; 95% CI , 0.52-0.68; Hispanic: aOR , 0.78; 95% CI , 0.66-0.94; and other: aOR , 0.54; 95% CI , 0.40-0.72). Compared with arrests in neighborhoods with an index score of 0, BCPR occurred less commonly for arrests with an index score of 1 ( aOR , 0.80; 95% CI , 0.70-0.91), 2 ( aOR , 0.75; 95% CI , 0.65-0.86), 3 ( aOR , 0.52; 95% CI , 0.45-0.61), and 4 ( aOR , 0.46; 95% CI , 0.36-0.59). Black children had an incrementally lower likelihood of BCPR with increasing index score while white children had an overall similar likelihood at most scores. Black children with an index of 4 were approximately half as likely to receive BCPR compared with white children with a score of 0. Conclusions Racial and neighborhood characteristics are associated with BCPR in pediatric OHCA . Targeted CPR training for nonwhite, low-education, and low-income neighborhoods may increase BCPR and improve pediatric OHCA outcomes.</p>

DOI

10.1161/JAHA.119.012637

Alternate Title

J Am Heart Assoc

PMID

31288613

Title

Identification of Predictive Biomarkers for Cytokine Release Syndrome after Chimeric Antigen Receptor T-cell Therapy for Acute Lymphoblastic Leukemia.

Year of Publication

2016

Number of Pages

664-79

Date Published

2016 06

ISSN Number

2159-8290

Abstract

<p><strong>UNLABELLED: </strong>Chimeric antigen receptor (CAR)-modified T cells with anti-CD19 specificity are a highly effective novel immune therapy for relapsed/refractory acute lymphoblastic leukemia. Cytokine release syndrome (CRS) is the most significant and life-threatening toxicity. To improve understanding of CRS, we measured cytokines and clinical biomarkers in 51 CTL019-treated patients. Peak levels of 24 cytokines, including IFNγ, IL6, sgp130, and sIL6R, in the first month after infusion were highly associated with severe CRS. Using regression modeling, we could accurately predict which patients would develop severe CRS with a signature composed of three cytokines. Results were validated in an independent cohort. Changes in serum biochemical markers, including C-reactive protein and ferritin, were associated with CRS but failed to predict development of severe CRS. These comprehensive profiling data provide novel insights into CRS biology and, importantly, represent the first data that can accurately predict which patients have a high probability of becoming critically ill.</p>

<p><strong>SIGNIFICANCE: </strong>CRS is the most common severe toxicity seen after CAR T-cell treatment. We developed models that can accurately predict which patients are likely to develop severe CRS before they become critically ill, which improves understanding of CRS biology and may guide future cytokine-directed therapy. Cancer Discov; 6(6); 664-79. ©2016 AACR.See related commentary by Rouce and Heslop, p. 579This article is highlighted in the In This Issue feature, p. 561.</p>

DOI

10.1158/2159-8290.CD-16-0040

Alternate Title

Cancer Discov

PMID

27076371

Title

Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States

Year of Publication

2016

Date Published

2016 Nov 12

ISSN Number

2168-6211

Abstract

<p><strong>Importance: </strong>There are few data on the prevalence or outcome of bystander cardiopulmonary resuscitation (BCPR) in children 18 years and younger.</p>

<p><strong>Objective: </strong>To characterize BCPR in pediatric out-of-hospital cardiac arrests (OHCAs).</p>

<p><strong>Design, Setting, and Participants: </strong>This analysis of the Cardiac Arrest Registry to Enhance Survival database investigated nontraumatic OHCAs in children 18 years and younger from January 2013 through December 2015.</p>

<p><strong>Exposures: </strong>Bystander CPR, which included conventional CPR and compression-only CPR.</p>

<p><strong>Main Outcomes and Measures: </strong>Overall survival and neurologically favorable survival, defined as a Cerebral Performance Category score of 1 or 2, at the time of hospital discharge.</p>

<p><strong>Results: </strong>Of the 3900 children younger than 18 years with OHCA, 2317 (59.4%) were infants, 2346 (60.2%) were female, and 3595 (92.2%) had nonshockable rhythms. Bystander CPR was performed on 1814 children (46.5%) and was more common for white children (687 of 1221 [56.3%]) compared with African American children (447 of 1134 [39.4%]) and Hispanic children (197 of 455 [43.3%]) (P &lt; .001). Overall survival and neurologically favorable survival were 11.3% (440 of 3900) and 9.1% (354 of 3900), respectively. On multivariable analysis, BCPR was independently associated with improved overall survival (adjusted proportion, 13.2%; 95% CI, 11.81-14.58; adjusted odds ratio, 1.57; 95% CI, 1.25-1.96) and neurologically favorable survival (adjusted proportion, 10.3%; 95% CI, 9.10-11.54; adjusted odds ratio, 1.50; 95% CI, 1.21-1.98) compared with no BCPR (overall survival: adjusted proportion, 9.5%; 95% CI, 8.28-10.69; neurologically favorable survival: adjusted proportion, 7.59%; 95% CI, 6.50-8.68). For those with data on type of BCPR, 697 of 1411 (49.4%) received conventional CPR and 714 of 1411 (50.6%) received compression-only CPR. On multivariable analysis, only conventional CPR (adjusted proportion, 12.89%; 95% CI, 10.69-15.09; adjusted odds ratio, 2.06; 95% CI, 1.51-2.79) was associated with improved neurologically favorable survival compared with no BCPR (adjusted proportion, 9.59%; 95% CI, 6.45-8.61). There was a significant interaction of BCPR with age. Among infants, conventional BCPR was associated with improved overall survival and neurologically favorable survival while compression-only CPR had similar outcomes to no BCPR.</p>

<p><strong>Conclusions and Relevance: </strong>Bystander CPR is associated with improved outcomes in pediatric OHCAs. Improving the provision of BCPR in minority communities and increasing the use of conventional BCPR may improve outcomes for children with OHCA.</p>

DOI

10.1001/jamapediatrics.2016.3643

Alternate Title

JAMA Pediatr

PMID

27837587

Title

Pediatric Medical Emergency Team Events and Outcomes: A Report of 3647 Events From the American Heart Association's Get With the Guidelines-Resuscitation Registry.

Year of Publication

2016

Number of Pages

57-64

Date Published

2016 Feb

ISSN Number

2154-1663

Abstract

<p><strong>OBJECTIVES: </strong>To describe the clinical characteristics and outcomes of a large, multicenter cohort of pediatric medical emergency team (MET) events occurring in US hospitals reported to the American Heart Association's Get With the Guidelines-Resuscitation registry.</p>

<p><strong>METHODS: </strong>We analyzed consecutive pediatric (&lt;18 years) MET events reported to the registry from January 2006 to February 2012.</p>

<p><strong>RESULTS: </strong>We identified 3647 MET events from 151 US hospitals: 3080 (84%) ward and 567 (16%) telemetry/step-down unit events; median age 3.0 years (interquartile range: 0.0-11.0); 54% male; median duration 29 minutes (interquartile range: 18-49). Triggers included decreased oxygen saturation (32%), difficulty breathing (26%), and staff concern (24%). Thirty-seven percent (1137/3059) were admitted within 24 hours before MET event. Within 24 hours before the MET event, 16% were transferred from a PICU, 24% from an emergency department, and 7% from a pediatric anesthesia care unit. Fifty-three percent of MET events resulted in transfer to a PICU; 3251 (89%) received nonpharmacologic interventions, 2135 (59%) received pharmacologic interventions, 223 (6.1%) progressed to an acute respiratory compromise event, and 17 events (0.5%) escalated to cardiopulmonary arrest during the event. Survival to hospital discharge was 93.3% (n=3299/3536).</p>

<p><strong>CONCLUSIONS: </strong>Few pediatric MET events progress to respiratory or cardiac arrest, but most require nonpharmacologic and pharmacologic intervention. Median duration of MET event was 29 minutes (interquartile range: 18-49), and 53% required transfer to a PICU. Events often occurred within 24 hours after hospital admission or transfer from the PICU, emergency department, or pediatric anesthesia care unit and may represent an opportunity to improve triage and other systems of care.</p>

DOI

10.1542/hpeds.2015-0132

Alternate Title

Hosp Pediatr

PMID

26813980

Title

A pragmatic checklist to identify pediatric ICU patients at risk for cardiac arrest or code bell activation.

Year of Publication

2016

Number of Pages

33-7

Date Published

2016 Feb

ISSN Number

1873-1570

Abstract

<p><strong>BACKGROUND: </strong>In-hospital cardiac arrest is a rare event associated with significant morbidity and mortality. The ability to identify the ICU patients at risk for cardiac arrest could allow the clinical team to prepare staff and equipment in anticipation.</p>

<p><strong>METHODS: </strong>This pilot study was completed at a large tertiary care pediatric intensive care unit to determine the feasibility of a simple checklist of clinical variables to predict deterioration. The daily checklist assessed patient risk for critical deterioration defined as cardiac arrest or code bell activation within 24h of the checklist screen. The Phase I checklist was developed by expert consensus and evaluated to determine standard diagnostic test performance. A modified Phase II checklist was developed to prospectively test the feasibility and bedside provider "number needed to train".</p>

<p><strong>RESULTS: </strong>For identifying patients requiring code bell activation, both checklists demonstrated a sensitivity of 100% with specificity of 76.0% during Phase I and 97.7% during Phase II. The positive likelihood ratio improved from 4.2 to 43.7. For identifying patients that had a cardiac arrest within 24h, the Phase I and II checklists demonstrated a sensitivity of 100% with specificity again improving from 75.7% to 97.6%. There was an improved positive likelihood ratio from 4.1 in Phase I to 41.9 in Phase II, with improvement of "number needed to train" from 149 to 7.4 providers.</p>

<p><strong>CONCLUSIONS: </strong>A novel high-risk clinical indicators checklist is feasible and provides timely and accurate identification of the ICU patients at risk for cardiac arrest or code bell activation.</p>

DOI

10.1016/j.resuscitation.2015.11.017

Alternate Title

Resuscitation

PMID

26703460

Title

Cytokine release syndrome after blinatumomab treatment related to abnormal macrophage activation and ameliorated with cytokine-directed therapy.

Year of Publication

2013

Number of Pages

5154-7

Date Published

2013 Jun 27

ISSN Number

1528-0020

Abstract

<p>Blinatumomab is a CD19/CD3-bispecific T-cell receptor-engaging (BiTE) antibody with efficacy in refractory B-precursor acute lymphoblastic leukemia. Some patients treated with blinatumomab and other T cell-activating therapies develop cytokine release syndrome (CRS). We hypothesized that patients with more severe toxicity may experience abnormal macrophage activation triggered by the release of cytokines by T-cell receptor-activated cytotoxic T cells engaged by BiTE antibodies and leading to hemophagocytic lymphohistiocytosis (HLH). We prospectively monitored a patient during blinatumomab treatment and observed that he developed HLH. He became ill 36 hours into the infusion with fever, respiratory failure, and circulatory collapse. He developed hyperferritinemia, cytopenias, hypofibrinogenemia, and a cytokine profile diagnostic for HLH. The HLH continued to progress after discontinuation of blinatumomab; however, he had rapid improvement after IL-6 receptor-directed therapy with tocilizumab. Patients treated with T cell-activating therapies, including blinatumomab, should be monitored for HLH, and cytokine-directed therapy may be considered in cases of life-threatening CRS. This trial was registered at www.clinicaltrials.gov as #NCT00103285.</p>

DOI

10.1182/blood-2013-02-485623

Alternate Title

Blood

PMID

23678006

Title

Correlations between first documented cardiac rhythms and preceding telemetry in patients with code blue events.

Year of Publication

2013

Number of Pages

225-8

Date Published

2013 Apr

ISSN Number

1553-5606

Abstract

<p><strong>BACKGROUND: </strong>Among in-hospital cardiac arrest (IHCA) patients, the first cardiac rhythm documented on resuscitation records (FDR) is often used as a surrogate for arrest etiology. Although the FDR generally represents the electrical activity at the time of cardiopulmonary resuscitation initiation, it may not be the ideal rhythm to infer the arrest etiology. We hypothesized that a rhythm present earlier-at the time of the code blue call-would frequently differ from the FDR, because the FDR might represent the later stage of a progressive cardiopulmonary process.</p>

<p><strong>OBJECTIVE: </strong>To evaluate agreement between FDR and telemetry rhythm at the time of code blue call.</p>

<p><strong>DESIGN: </strong>Cross-sectional study.</p>

<p><strong>SETTING: </strong>A 750-bed adult tertiary care hospital and a 240-bed adult inner city community hospital.</p>

<p><strong>PATIENTS: </strong>Adult general ward patients monitored on the hospital's telemetry system during the 2 minutes prior to a code blue call for IHCA.</p>

<p><strong>INTERVENTION: </strong>None.</p>

<p><strong>MEASUREMENTS: </strong>Agreement between FDR and telemetry rhythm.</p>

<p><strong>RESULTS: </strong>Among 69 IHCAs, agreement between FDR and telemetry was 65% (kappa = 0.37). Among 17 events with FDRs of ventricular tachyarrhythmia (VTA), telemetry showed VTA in 12 (71%) and other organized rhythms in 5 (29%). Among 12 events with first documented rhythms of asystole, telemetry showed asystole in 3 (25%), VTA in 1 (8%), and other organized rhythms in 8 (67%).</p>

<p><strong>CONCLUSIONS: </strong>The FDR had only fair agreement with the telemetry rhythm at the time of code blue call. The telemetry rhythm may be a useful adjunct to the FDR when investigating arrest etiology.</p>

DOI

10.1002/jhm.2028

Alternate Title

J Hosp Med

PMID

23495109

Title

Outcome of pediatric acute myeloid leukemia patients receiving intensive care in the United States.

Year of Publication

2014

Number of Pages

112-20

Date Published

02/2014

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVE: </strong>Children with acute myeloid leukemia are at risk for sepsis and organ failure. Outcomes associated with intensive care support have not been studied in a large pediatric acute myeloid leukemia population. Our objective was to determine hospital mortality of pediatric acute myeloid leukemia patients requiring intensive care.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study of children hospitalized between 1999 and 2010. Use of intensive care was defined by utilization of specific procedures and resources. The primary endpoint was hospital mortality.</p>

<p><strong>SETTING: </strong>Forty-three children's hospitals contributing data to the Pediatric Health Information System database.</p>

<p><strong>PATIENTS: </strong>Patients who are newly diagnosed with acute myeloid leukemia and who are 28 days through 18 years old (n = 1,673) hospitalized any time from initial diagnosis through 9 months following diagnosis or until stem cell transplant. A reference cohort of all nononcology pediatric admissions using the same intensive care resources in the same time period (n = 242,192 admissions) was also studied.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>One-third of pediatric patients with acute myeloid leukemia (553 of 1,673) required intensive care during a hospitalization within 9 months of diagnosis. Among intensive care admissions, mortality was higher in the acute myeloid leukemia cohort compared with the nononcology cohort (18.6% vs 6.5%; odds ratio, 3.23; 95% CI, 2.64-3.94). However, when sepsis was present, mortality was not significantly different between cohorts (21.9% vs 19.5%; odds ratio, 1.17; 95% CI, 0.89-1.53). Mortality was consistently higher for each type of organ failure in the acute myeloid leukemia cohort versus the nononcology cohort; however, mortality did not exceed 40% unless there were four or more organ failures in the admission. Mortality for admissions requiring intensive care decreased over time for both cohorts (23.7% in 1999-2003 vs 16.4% in 2004-2010 in the acute myeloid leukemia cohort, p = 0.0367; and 7.5% in 1999-2003 vs 6.5% in 2004-2010 in the nononcology cohort, p &lt; 0.0001).</p>

<p><strong>CONCLUSIONS: </strong>Pediatric patients with acute myeloid leukemia frequently required intensive care resources, with mortality rates substantially lower than previously reported. Mortality also decreased over the time studied. Pediatric acute myeloid leukemia patients with sepsis who required intensive care had a mortality comparable to children without oncologic diagnoses; however, overall mortality and mortality for each category of organ failure studied was higher for the acute myeloid leukemia cohort compared with the nononcology cohort.</p>

DOI

10.1097/PCC.0000000000000042

Alternate Title

Pediatr Crit Care Med

PMID

24366507

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