Search

OBJECTIVES To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy. DESIGN Retrospective study of a multicenter registry database. SETTING Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers. PATIENTS Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15). CONCLUSIONS Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.

Objective: To determine the incidence, severity, and risk factors of postoperative acute kidney injury in pediatric liver transplant patients with and without inborn errors of metabolism. Design: Retrospective cohort study. Setting: Single-center PICU. Patients: All children less than or equal to 18 years old who received a liver transplant between January 2009 and July 2019. Interventions: None. Measurements and Main Results: Following exclusion criteria there were 92 transplant encounters. After excluding patients who received combined kidney-liver transplantation, acute kidney injury occurred in 57% of patients (N = 49), with 25.6% (N = 22) stage 1, 15.1% (N = 13) stage 2, and 16.3% (N = 14) stage 3. In an adjusted analysis, metabolic indication for transplant was not significantly associated with presence of acute kidney injury (p = 0.45). For the subset of patients without inborn errors of metabolism, the odds of having acute kidney injury was 1.50 (95% CI: 1.00-2.26) for each 1-unit increase in preoperative INR after adjusting for the covariates of age, preoperative albumin, CMV status of donor, and preoperative creatinine. In the full cohort, as well as the sample of children without inborn errors of metabolism, presence of acute kidney injury was associated with longer total hospital stay as well as number of ICU days. Conclusions: Acute kidney injury in the early postoperative period is common in pediatric liver transplant patients (57%), 31.4% of whom had severe disease. In patients without inborn errors of metabolism, each unit increase in preoperative INR suggests a higher risk of acute kidney injury after adjusting for covariates including preoperative creatinine. This finding suggests an association between the severity of preoperative synthetic liver function and the risk of developing postoperative acute kidney injury which requires further investigation.

Abstarct To investigate the use of two-site regional oxygen saturations (rSO2) and end tidal carbon dioxide (EtCO2) to assess the effectiveness of resuscitation and return of spontaneous circulation (ROSC). Eight mechanically ventilated juvenile swine underwent 28 ventricular fibrillatory arrests with open cardiac massage. Cardiac massage was administered to achieve target pulmonary blood flow (PBF) as a percentage of pre-cardiac arrest baseline. Non-invasive data, including, EtCO2, cerebral rSO2 (C-rSO2) and renal rSO2 (R-rSO2) were collected continuously. Our data demonstrate the ability to measure both rSO2 and EtCO2 during CPR and after ROSC. During resuscitation EtCO2 had a strong correlation with goal CO with r = 0.83 (p

The kinetics of carbon dioxide elimination (VCO2) may be used as a surrogate for pulmonary blood flow. As such, we can apply a novel use of volumetric capnography to assess hemodynamic stability in patients requiring extracorporeal membrane oxygenation (ECMO). We report our experience of pediatric patients requiring ECMO support who were monitored using volumetric capnography. We describe the use of VCO2 and its association with successful decannulation. This is a prospective observational study of pediatric patients requiring ECMO support at The Children's Hospital at Montefiore from 2017 to 2019. A Respironics NM3 monitor was applied to each patient. Demographics, hemodynamic data, blood gases, and VCO2 (mL/min) data were collected. Data were collected immediately prior to and after decannulation. Over the course of the study period, seven patients were included. Predecannulation VCO2 was higher among patients who were successfully decannulated than nonsurvivors (109 [35, 230] vs. 12.4 [7.6, 17.2] mL/min), though not statistically significant. Four patients (57%) survived without further mechanical support; two (29%) died, and one (14%) was decannulated to Berlin. Predecannulation VCO2 appears to correlate with hemodynamic stability following decannulation. This case series adds to the growing literature describing the use of volumetric capnography in critical care medicine, particularly pediatric patients requiring ECMO. Prospective studies are needed to further elucidate the use of volumetric capnography and optimal timing for ECMO decannulation.

In this report, we describe the case of a 5-year-old male with SARS-CoV-2 associated MIS-C with progressive respiratory failure and vasoplegic shock requiring extracorporeal support. At presentation, reverse transcription-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was negative, however, SARS-CoV2 antibody testing was positive. Multiple inflammatory markers and cardiac biomarkers were elevated. Echocardiogram demonstrated mildly depressed left ventricular function and no coronary anomalies noted. The patient required mechanical ventilation, vasopressors, and eventually extracorporeal membrane oxygenation (ECMO) for profound circulatory shock and progressive respiratory failure. During his clinical course, recovery of cardiac function was demonstrated however, a middle cerebral artery infarct and left frontal subarachnoid hemorrhage was suffered which ultimately the patient succumbed to. To the best of our knowledge, this is the youngest previously healthy child who had multi-system hyperinflammatory syndrome requiring ECMO support and the first case of SARS-CoV-2 related pediatric stroke. Clinical Trial Registration: None

Multisystem inflammatory syndrome in children (MIS-C) presents with fever, inflammation and pathology of multiple organs in individuals under 21 years of age in the weeks following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Although an autoimmune pathogenesis has been proposed, the genes, pathways and cell types causal to this new disease remain unknown. Here we perform RNA sequencing of blood from patients with MIS-C and controls to find disease-associated genes clustered in a co-expression module annotated to CD56dimCD57+ natural killer (NK) cells and exhausted CD8+ T cells. A similar transcriptome signature is replicated in an independent cohort of Kawasaki disease (KD), the related condition after which MIS-C was initially named. Probing a probabilistic causal network previously constructed from over 1,000 blood transcriptomes both validates the structure of this module and reveals nine key regulators, including TBX21, a central coordinator of exhausted CD8+ T cell differentiation. Together, this unbiased, transcriptome-wide survey implicates downregulation of NK cells and cytotoxic T cell exhaustion in the pathogenesis of MIS-C., Multisystem inflammatory syndrome in children (MIS-C) onsets in COVID-19 patients with manifestations similar to Kawasaki disease (KD). Here the author probe the peripheral blood transcriptome of MIS-C patients to find signatures related to natural killer (NK) cell activation and CD8+ T cell exhaustion that are shared with KD patients.

Objective To assess clinical characteristics and outcomes of severe acute respiratory syndrome coronavirus 2-associated multisystem inflammatory syndrome in children (MIS-C). Study design Children with MIS-C admitted to pediatric intensive care units in New York City between April 23 and May 23, 2020, were included. Demographic and clinical data were collected. Results Of 33 children with MIS-C, the median age was 10 years; 61% were male; 45% were Hispanic/Latino; and 39% were black. Comorbidities were present in 45%. Fever (93%) and vomiting (69%) were the most common presenting symptoms. Depressed left ventricular ejection fraction was found in 63% of patients with median ejection fraction of 46.6% (IQR, 39.5-52.8). C-reactive protein, procalcitonin, d-dimer, and pro-B-type natriuretic peptide levels were elevated in all patients. For treatment, intravenous immunoglobulin was used in 18 (54%), corticosteroids in 17 (51%), tocilizumab in 12 (36%), remdesivir in 7 (21%), vasopressors in 17 (51%), mechanical ventilation in 5 (15%), extracorporeal membrane oxygenation in 1 (3%), and intra-aortic balloon pump in 1 (3%). The left ventricular ejection fraction normalized in 95% of those with a depressed ejection fraction. All patients were discharged home with median duration of pediatric intensive care unit stay of 4.7 days (IQR, 4-8 days) and a hospital stay of 7.8 days (IQR, 6.0-10.1 days). One patient (3%) died after withdrawal of care secondary to stroke while on extracorporeal membrane oxygenation. Conclusions Critically ill children with coronavirus disease-2019-associated MIS-C have a spectrum of severity broader than described previously but still require careful supportive intensive care. Rapid, complete clinical and myocardial recovery was almost universal.

Initially, children were thought to be spared from disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a month into the epidemic, a novel multisystem inflammatory syndrome in children (MIS-C) emerged. Herein, we report on the immune profiles of nine MIS-C cases. All MIS-C patients had evidence of prior SARS-CoV-2 exposure, mounting an antibody response with intact neutralization capability. Cytokine profiling identified elevated signatures of inflammation (IL-18 and IL-6), lymphocytic and myeloid chemotaxis and activation (CCL3, CCL4, and CDCP1), and mucosal immune dysregulation (IL-17A, CCL20, and CCL28). Immunophenotyping of peripheral blood revealed reductions of non-classical monocytes, and subsets of NK and T lymphocytes, suggesting extravasation to affected tissues. Finally, profiling the autoantigen reactivity of MIS-C plasma revealed both known disease-associated autoantibodies (anti-La) and novel candidates that recognize endothelial, gastrointestinal, and immune-cell antigens. All patients were treated with anti-IL-6R antibody and/or IVIG, which led to rapid disease resolution., Graphical Abstract, Highlights • The MIS-C anti-SARS-CoV-2 antibody repertoire resembles a convalescent response • Cytokine profiling indicates myeloid cell chemotaxis and mucosal inflammation • Mass cytometry uncovers immune cell activation and egress to the periphery • MIS-C autoantibodies target organ systems central to MIS-C pathology, Insights into the cellular and serological immune dysfunction underlying MIS-C, a novel pediatric inflammatory syndrome associated with SARS-CoV-2 infection, reveal potential autoantibodies that may link organ systems relevant to pathology.

The aim of this study was to examine the use of volumetric capnography monitoring to assess cardiopulmonary resuscitation (CPR) effectiveness by correlating it with cardiac output (CO), and to evaluate the effect of epinephrine boluses on both end-tidal carbon dioxide (EtCO (2) ) and the volume of CO (2) elimination (VCO (2) ) in a swine ventricular fibrillation cardiac arrest model. Planned secondary analysis of data collected to investigate the use of noninvasive monitors in a pediatric swine ventricular fibrillation cardiac arrest model was performed. Twenty-eight ventricular fibrillatory arrests with open cardiac massage were conducted. During CPR, EtCO (2) and VCO (2) had strong correlation with CO, measured as a percentage of baseline pulmonary blood flow, with correlation coefficients of 0.83 ( p

Early surgical intervention for children with infective endocarditis (IE) and cerebrovascular sequelae has significant risks, resulting in practice variation amongst pediatric cardiologists, intensivists, and cardiothoracic surgeons. The limited pediatric consensus recommendations make decision making for practitioners challenging. The added risk of multiorgan dysfunction syndrome can make these decisions even more difficult. We present the case of a 14-year-old with IE and resultant multiorgan dysfunction syndrome including cerebrovascular complication, successfully treated by primary valve repair within the 1st week of diagnosis.

For decades, physicians have administered corticosteroids in the perioperative period to infants undergoing heart surgery with cardiopulmonary bypass (CPB) to reduce the post-operative systemic inflammatory response to CPB. Some question this practice because steroid efficacy has not been conclusively demonstrated and because some studies indicate that steroids could have harmful effects. STRESS is a randomized, placebo-controlled, double blind, multi-center trial designed to evaluate safety and efficacy of perioperative steroids in infants (age < 1 year) undergoing heart surgery with CPB. Participants (planned enrollment = 1200) are randomized 1:1 to methylprednisolone (30mg/kg) administered into the CPB pump prime versus placebo. The trial is nested within the existing infrastructure of the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). The primary outcome is a global rank score of mortality, major morbidities and hospital length of stay with components ranked commensurate with their clinical severity. Secondary outcomes include several measures of major post-operative morbidity, post-operative hospital length of stay and steroid-related safety outcomes including prevalence of hyperglycemia and post-operative infectious complications. STRESS will be one of the largest trials ever conducted in children with heart disease and will answer a decades old question related to safety and efficacy of perioperative steroids in infants undergoing heart surgery with CPB. The pragmatic “trial within a registry” design may provide a mechanism for conducting low cost, high efficiency trials in a heretofore-understudied patient population. Trial Registration Number

Aim Approximately 40% of children who have an in-hospital cardiac arrest (IHCA) in the US survive to discharge. We aimed to evaluate the impact of post-cardiac arrest hypotension during targeted temperature management following IHCA on survival to discharge. Methods This is a secondary analysis of the therapeutic hypothermia after pediatric cardiac arrest in-hospital (THAPCA-IH) trial. “Early hypotension” was defined as a systolic blood pressure less than the fifth percentile for age and sex for patients not treated with extracorporeal membrane oxygenation (ECMO) or a mean arterial pressure less than fifth percentile for age and sex for patients treated with ECMO during the first 6 h of temperature intervention. The primary outcome was survival to hospital discharge. Results Of 299 children, 142 (47%) patients did not receive ECMO and 157 (53%) received ECMO. Forty-two of 142 (29.6%) non-ECMO patients had systolic hypotension. Twenty-three of 157 (14.7%) ECMO patients had mean arterial hypotension. After controlling for confounders of interest, non-ECMO patients who had early systolic hypotension were less likely to survive to hospital discharge (40.5% vs. 72%; adjusted OR [aOR] 0.34; 95%CI, 0.12–0.93). There was no difference in survival to discharge by blood pressure groups for children treated with ECMO (30.4% vs. 49.3%; aOR = 0.60; 95%CI, 0.22–1.63). Conclusions In this secondary analysis of the THAPCA-IH trial, in patients not treated with ECMO, systolic hypotension within 6 h of temperature intervention was associated with lower odds of discharge survival. Blood pressure groups in patients treated with ECMO were not associated with survival to discharge.

SummaryObjective Thrombocytopenia and acute kidney injury (AKI) are common following pediatric cardiac surgery with cardiopulmonary bypass (CPB). However, the relationship between postoperative nadir platelet counts and AKI has not been investigated in the pediatric population. Our objective was to investigate this relationship and examine independent predictors of AKI. Design After IRB approval, we performed a retrospective review of the institution's medical records and database. Setting: This study was performed at a single institution over a 5-year period. Patients: We included patients

Pediatric cardiac critical care medicine plays a central role in the care of patients with complex congenital and acquired heart disease. Over the last two decades, specialized cardiac intensive care units have emerged as central components in the management of critically ill neonatal, pediatric, and adult patients with congenital and/or acquired heart disease. Although data regarding the optimal method of care delivery to this specific patient population continue to emerge, there are significant center variations based on surgical volume, medical staff organization, and space allocation. What seems to remain paramount in the care of this highly specialized patient population is that a dedicated team of professionals be tasked with the comprehensive care of critically ill pediatric and adult patients with congenital and/or acquired heart disease.

The present study assessed the correlations between cerebral regional saturation detected by near infrared spectroscopy (NIRS) and cardiac index (CI) measured by pulmonary artery catheter. This was a retrospective cohort study conducted in the cardiac intensive care unit in a tertiary care children's hospital. Patients younger than 18 years of age who underwent heart transplantation and had a pulmonary artery catheter on admission to the pediatric cardiac intensive care unit between January, 2010, and August, 2013, were included. There were no interventions. A total of 10 patients were included with median age of 14 years (range, 7–17). Indications for transplantation were dilated cardiomyopathy ( n = 9) and restrictive cardiomyopathy ( n = 1). Mixed venous oxygen saturation (SvO (2) ), cerebral regional tissue saturation (rSO (2) ), and CI were recorded hourly for 8 to 92 hours post-transplantation. Spearman's rank correlation coefficient was used to assess correlations between SvO (2) and cerebral rSO (2) and between CI and cerebral rSO (2) . A total of 410 data points were collected. Median, 25th and 75th percentiles of cerebral rSO (2) , CI, and SvO (2) were 65% (54–69), 2.9 L/min/m (2) (2.2–4.0), and 75% (69–79), respectively. The correlation coefficient between cerebral rSO (2) and CI was 0.104 ( p = 0.034) and that for cerebral rSO (2) and SvO (2) was 0.11 ( p = 0.029). The correlations between cerebral rSO (2) and CI and between cerebral rSO (2) and SvO (2) were weak. Cerebral rSO (2) as detected by NIRS may not be an accurate indicator of CI in critically ill patients.

BackgroundTherapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited.MethodsWe conducted this trial of two targeted temperature interventions at 38 children's hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest.ResultsA total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality.ConclusionsIn comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

To describe the current use of noninvasive monitoring compared with traditional invasive monitoring in Pediatric Critical Care Medicine (PCCM) accredited fellowship programs in the United States. A web-based survey with the primary aim of describing the utilization of noninvasive monitoring compared with invasive monitoring was distributed to PCCM program directors (PDs) at the 64 accredited fellowship training programs. Questions focused on demographics and the utilization of invasive and noninvasive monitoring for specific patient populations and disease states. Forty-two (66%) PDs responded to the survey. Capnography and near-infrared spectroscopy (NIRS) were the most commonly reported noninvasive monitoring technology. Arterial and central venous catheters were widely used. Other invasive monitoring devices were used sparingly. Despite widespread use of both invasive and noninvasive monitoring in academic pediatric critical care units across the United States, there is significant variability in the use of noninvasive monitoring compared with invasive monitoring. Further investigation is needed to define the standard of care for the use of noninvasive monitors as practitioners attempt to optimize care while minimizing risks and complications.

OBJECTIVE: To investigate clinical characteristics associated with 12-month survival and neurobehavioural function among children recruited to the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital trial. METHODS: Children (n=329) with in-hospital cardiac arrest who received chest compressions for ≥2 minutes, were comatose, and required mechanical ventilation after return of circulation were included. Neurobehavioural function was assessed using the Vineland Adaptive Behaviour Scale, second edition (VABS-II) at baseline (reflecting pre-arrest status) and 12 months post-arrest. Norms for VABS-II are 100 (mean) ± 15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival, 12-month survival with VABS-II decreased by ≤15 points from baseline, and 12-month survival with VABS-II ≥70. RESULTS: Asystole as the initial arrest rhythm, administration of >4 adrenaline doses, and higher post-arrest blood lactate concentration were independently associated with lower 12-month survival; an adrenaline dosing interval of 3 to

Over 150 invited experts presented to almost 6000 participants at the most recent American Association for Respiratory Care International Congress. These participants represented a broad international audience with a range of expertise that included respiratory therapists, physicians, nurses and others. While the program incorporated an extensive curriculum, the theme of lung protective ventilation was highlighted throughout the Congress. Experts reviewed the current evidence regarding the risk for ventilator-induced lung injury in mechanically ventilated patients without pre-existing lung disease and in those with acute lung injury. In addition, several experts reviewed the cutting edge approach of extracorporeal membrane oxygenation as a lung protective approach.

Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.

Objective: The treatment of pain has gained momentum in health care around the world. Nevertheless, pain is undertreated, particularly in the developing world. We sought to compare patient and healthcare practitioner perspectives of postoperative pain and assess perioperative analgesia utilisation in a tertiary care hospital in a resource-limited setting.Design: We conducted a prospective observational study.Setting and subjects: Postoperative patients and their respective recovery room nurses were studied at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.Outcome measures: Patients were surveyed 1–4 hours postoperatively. Pain severity on a numerical rating scale (NRS) and patient satisfaction with the pain control were assessed. Recovery room nurses who were responsible for administering the pain medications were surveyed on their perceptions of their patients' pain. Patient demographic information, diagnoses, surgery type, mode of anaesthesia and perioperative analgesia use were recorded.Re...

Background Hospitalized infants requiring cardiopulmonary resuscitation (CPR) represent a high-risk group. Recent data on risk factors for mortality following CPR in this population are lacking. Aims We hypothesized that infant demographic characteristics, diagnoses, and levels of cardiopulmonary support at the time of CPR requirement would be associated with survival to hospital discharge following CPR. Study design Retrospective cohort study. Subjects All infants receiving CPR on day of life 2 to 120 admitted to 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. Outcomes measures We collected data on demographics, interventions, center volume, and death prior to NICU discharge. We evaluated predictors of death after CPR using multivariable logistic regression with generalized estimating equations to account for clustering of the data by center. Results Our cohort consisted of 2231 infants receiving CPR. Of these, 1127 (51%) survived to hospital discharge. Lower gestational age, postnatal age, 5-min APGAR, congenital anomaly, and markers of severity of illness were associated with higher mortality. Mortality after CPR did not change significantly over time (Cochran–Armitage test for trend p = 0.35). Conclusions Mortality following CPR in infants is high, particularly for less mature, younger infants with congenital anomalies and those requiring cardiopulmonary support prior to CPR. Continued focus on at risk infants may identify targets for CPR prevention and improve outcomes.

Background Pulmonary hypertension causes increased morbidity and mortality in adults after heart transplantation. The effect of markedly elevated pulmonary vascular resistance (PVR) on post-transplant outcomes in children has not been well described. Methods Outcomes were compared in a retrospective study between 58 children with an elevated PVR index (PVRI) ≥ 6 U/m 2 and 205 children with a PVRI 2 . Patients who did and did not respond to acute vasodilator testing and patients who underwent transplant before (pre-1995) and after (post-1995) the availability of inhaled nitric oxide (iNO) were compared. Results The pre-transplant diagnoses, and cardiopulmonary bypass and donor ischemic times were similar between the high and low PVRI groups. High PVRI patients were older at transplant (12 ± 6.2 vs 8 ± 7.1 years, p = 0.002 ). The post-transplant inotrope score was higher in the high PVRI group (12 ± 12 vs 2 ± 2, p = 0.0001) and 1-year survival was worse (76% vs 81%, p = 0.03). The PVRI fell to 2 with acute vasodilator testing in 21 of 49 (42%) high PVRI patients. RV failure occurred in 4 (19%) of the responders and in 14 (50%) of the non-responders ( p = 0.037). One responder (5%) and 4 non-responders (14%) died of RV failure. In the period after 1995, the year iNO became clinically available, the select group of high PVRI patients who received iNO preemptively had a lower incidence of post-transplant RV failure than the group that did not receive preemptive iNO (13% vs 54%, p = 0.04). Conclusions Pre-transplant vasodilator testing identified patients at higher risk for RV failure. Patients who did not respond to vasodilator testing had an increased incidence of RV failure and death from RV failure. Preemptive use of iNO was associated with a decreased incidence of RV failure.

Importance Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described during targeted temperature management. Objective To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. Design, setting, and participants This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1, 2009, through December 31, 2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5, 2016, through June 13, 2017. Exposures Hypotension. Main outcomes and measure Survival to hospital discharge. Results Of 292 children (194 boys [66.4%] and 98 girls [33.6%]; median age, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) or rewarming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74). Conclusions and relevance In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.