Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Registry

Abstract

Objectives: The main objectives of this study were to describe in-hospital acute respiratory compromise among children (< 18 yr old), and its association with cardiac arrest and in-hospital mortality.

Design: Observational study using prospectively collected data.

Setting: U.S. hospitals reporting data to the "Get With The Guidelines-Resuscitation" registry.

Patients: Pediatric patients (< 18 yr old) with acute respiratory compromise. Acute respiratory compromise was defined as absent, agonal, or inadequate respiration that required emergency assisted ventilation and elicited a hospital-wide or unit-based emergency response.

Interventions: None.

Measurements and main results: The primary outcome was in-hospital mortality. Cardiac arrest during the event was a secondary outcome. To assess the association between patient, event, and hospital characteristics and the outcomes, we created multivariable logistic regressions models accounting for within-hospital clustering. One thousand nine hundred fifty-two patients from 151 hospitals were included. Forty percent of the events occurred on the wards, 19% in the emergency department, 25% in the ICU, and 16% in other locations. Two hundred eighty patients (14.6%) died before hospital discharge. Preexisting hypotension (odds ratio, 3.26 [95% CI, 1.89-5.62]; p < 0.001) and septicemia (odds ratio, 2.46 [95% CI, 1.52-3.97]; p < 0.001) were associated with increased mortality. The acute respiratory compromise event was temporally associated with a cardiac arrest in 182 patients (9.3%), among whom 46.2% died. One thousand two hundred eight patients (62%) required tracheal intubation during the event. In-hospital mortality among patients requiring tracheal intubation during the event was 18.6%.

Conclusions: In this large, multicenter study of acute respiratory compromise, 40% occurred in ward settings, 9.3% had an associated cardiac arrest, and overall in-hospital mortality was 14.6%. Preevent hypotension and septicemia were associated with increased mortality rate.

Figure 1. Patient inclusion/exclusion

Of 4590 acute respiratory compromise (ARC) events in the registry, 1952 were included in this study. 284 (14.6%) died before hospital discharge.

Figure 2. Outcomes over time

Proportion of patients dying (black circles) and progressing to cardiac arrest (grey squares) according to the year of the event. Error bars represent exact 95% confidence intervals. There was a significant unadjusted decreased in in-hospital mortality over time (OR per year 0.92 [95%CI: 0.88, 0.96]) that remained significant in multivariable analysis in the non-imputed cohort but not in the imputed cohort.