Identification of Post-cardiac Arrest Blood Pressure Thresholds Associated With Outcomes in Children: An ICU-Resuscitation Study

INTRODUCTION: Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge. METHODS: We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. RESULTS: Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP \u3e 10th percentile and DBP \u3e 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p \u3c 0.001). CONCLUSIONS: Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP \u3e 10th percentile for age and DBP \u3e 50th percentile for age during the first 6 h post-arrest

Reducing Insulin Errors in a Pediatric Hospital

A medication error is defined by the Agency for Healthcare Research and Quality as “an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication”. Medication errors cause significant morbidity and mortality, and contribute to excessive health care spending. Pediatric patients can have up to three times the medication error rate of adults, leading to 7,000 deaths annually. The aim of this study was to identify opportunities to improve insulin safety at the Nemours Children’s Hospital, Delaware. The quality improvement methods employed during this study included the use of process mapping and failure mode and effects analysis (FMEA). Twenty-one multidisciplinary team members convened to map the process of a patient with an established diagnosis of diabetes mellitus presenting with diabetic ketoacidosis from their presentation to the emergency department to their discharge home. Process mapping revealed that nine roles and 71 steps were involved in this process. A total of 103 failure modes were identified in 56 steps of the process, with as many as six failure modes for one step. Risk priority numbers ranged from one to 490. In line with previously published work on insulin errors, failure modes included lapses in communication, misinterpretation of insulin recommendations/orders, and electronic failures