Elsevier

Resuscitation

Volume 89, April 2015, Pages 106-113
Resuscitation

Clinical paper
Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest – A report from the American Heart Association Get With The Guidelines®-Resuscitation

https://doi.org/10.1016/j.resuscitation.2015.01.007Get rights and content

Abstract

Background

Despite limited recommendations for using sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR), we hypothesized that SB continues to be used frequently during pediatric in-hospital cardiac arrest (IHCA) and that its use varies by hospital-specific, patient-specific, and event-specific characteristics.

Methods

We analyzed 3719 pediatric (<18 years) index pulseless CPR events from the American Heart Association Get With The Guidelines-Resuscitation database from 1/2000 to 9/2010.

Results

SB was used in 2536 (68%) of 3719 CPR events. Incidence of SB use between 2000 and 2005 vs. 2006 and 2010 was 71.1% vs. 66.2% (P = 0.002). The primary outcome was survival to discharge. Secondary outcomes included 24-h survival and neurologic outcome. Multivariable logistic regression analyzed the association between SB use and outcomes. SB had increased use an ICU location, metabolic/electrolyte disturbance, prolonged CPR, pVT/VF, and concurrently with other pharmacologic interventions. Adjusting for confounding factors, SB use was associated with decreased 24-h survival (aOR 0.83, 95% CI: 0.69, 0.99) and decreased survival to discharge (aOR 0.80; 95% CI: 0.65, 0.97). Inclusion of metabolic/electrolyte abnormalities, hyperkalemia, and toxicologic abnormalities only (n = 674), SB use was not associated with worse outcomes or unfavorable neurologic outcome.

Conclusions

SB is used frequently during pediatric pulseless IHCA, yet there is a significant trend toward less routine use over the last decade. Because SB is more likely to be used in an ICU, with prolonged CPR, and concurrently with other pharmacologic interventions; its use during CPR may be associated with poor prognosis due to an association with “last ditch” efforts of resuscitation rather than causation.

Introduction

The use of sodium bicarbonate (SB) during adult and pediatric cardiopulmonary resuscitation (CPR) is discouraged because of a lack of evidence of benefit, and concerns regarding possible harm. The rationale for its use in cardiopulmonary arrest (CPA) was based on the premise that acidemia impairs myocardial performance and attenuates heart rate, cardiac contractility and thus cardiac output in response to catecholamines. However, adult randomized controlled trials failed to demonstrate the benefit of buffer therapy in adult out-of-hospital cardiac arrest,1, 2, 3 and a recent adult study even failed to demonstrate the benefit of using SB during prolonged CPR.4 There is little data that supports the use of SB during adult cardiac arrest, and no substantive data to support its use in the resuscitation of children in cardiac arrest.

The 2005 American Heart Association's (AHA) Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) guidelines state that the routine administration of SB has not been shown to improve outcome of resuscitation (Class Indeterminate), but may be used in certain resuscitation situations, such as pre-existing metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose. SB may be considered for prolonged arrest after effective ventilations and chest compressions and epinephrine have been administered (Class III, Level of Evidence B).5, 6 In the 2010 ACLS and PALS guidelines the routine administration of SB was not recommended in cardiac arrest (Class III, Level of Evidence B), but could be administered for treatment of some toxidromes or certain resuscitation situations such as hyperkalemic cardiac arrest. The administration of SB for prolonged arrest was no longer recommended.7

Specific patterns of SB use during pediatric in-hospital cardiac arrest (IHCA), and its effect on survival have not been reported since these guidelines were published. The American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) database is a large, multicenter registry that prospectively and rigorously documents adult and pediatric IHCA.8 We conducted this study using the GWTG-R registry to characterize SB use during pediatric pulseless IHCA. We hypothesized that SB continues to be used frequently during pediatric IHCA and that its use varies by hospital-specific, patient-specific, and event-specific characteristics.

Section snippets

Methods

Study patients were derived from the GWTG-R registry (formerly known as the National Registry of Cardiopulmonary Resuscitation or NRCPR). This is a large, hospital-based, clinical registry of in-hospital cardiac arrests that is sponsored by the AHA with voluntary, fee-based membership. Its design was previously described in detail.9, 10 Hospitals voluntarily participate in the database for the primary purpose of quality improvement, and as such are not required to obtain institutional review

Results

A total of 3719 index children received CPR for pediatric pulseless IHCA. Of these, 2536 (68%) received SB during CPR (Fig. 1). The incidence of SB use by age was 366 (59.4%) of 616 for infants <1 year of age, 822 (70.0%) of 1174 children age 1–7 years, and 1348 (69.9%) of 1929 children age 8–17 years. The incidence of SB use by years is depicted in Fig. 2. The incidence of SB use between 2000 and 2005 vs. 2006 and 2010 was 71.1% vs. 66.2% (P = 0.002). Pre-event and event characteristics of the

Discussion

This is the largest study analyzing the administration of SB during pediatric pulseless IHCA and its association with outcome. It documents that SB use during CPR is strongly influenced by hospital-specific, patient-specific, and arrest-specific characteristics. This report of 3719 consecutive children with pulseless IHCA documents frequent use of SB during the resuscitation of 2536 (68%) children, yet there is a significant trend toward less routine use over the last decade. The data from this

Conclusions

Sodium bicarbonate is administered during CPR in well over half of all pediatric pulseless IHCA events, yet data analysis from the GWTG-R registry confirms that the routine use of SB is steadily and significantly decreasing in prevalence, as the AHA guidelines recommend. The use of SB during CPR is strongly influenced by hospital-specific, patient-specific, and arrest-specific characteristics. The GWTG-R registry analysis suggests that the routine use of SB, even when controlling for

Funding

The Chloe Duyck Memorial Fund at Medical City Children's Hospital provided funding for the statistical analysis of this study but did not influence the design, conduct, management, analysis, or interpretation of the study.

Conflict of interest statement

None.

Acknowledgements

We gratefully acknowledge Qilong Yi, PhD, MSc, and ScienceDocs, Inc. for statistical analysis and all of that data abstractors, staff, and investigators who work so hard to contribute data to the American Heart Association Get With The Guidelines-Resuscitation registry.

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      Citation Excerpt :

      Therefore, different characteristics between the SB and no SB groups and unidentified confounders may have existed in our study. For example, Raymond et al. revealed that SB was administered more frequently to patients with prolonged CPR, metabolic or electrolyte disturbance, ventricular fibrillation or pulseless ventricular tachycardia during resuscitation, or hypotension before cardiac arrest.11 Thus, further prospective studies are necessary to address these confounding factors.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.01.007.

    1

    See Appendix A for Get With The Guidelines-Resuscitation Investigators.

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