Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest
Hospital Cardiac Arrest
Pediatric Critical Care Medicine
September 2023 by Dr Andrew Chazan
Study type - A retrospective multicenter international cohort study
Methods - Data gathered from 2015 to 2020 in more than 50 paediatric hospitals internationally, looking at any patients 18 years or less who suffered in hospital cardiac arrest (IHCA) and had one or more shock delivery. Exclusion was any rhythm strips that were indecipherable due to artifact. Rhythm strips recorded by the defibrillators were examined independently by a paediatric electrophysiologist and a paediatric cardiac intensivist and divided into three groups- appropriate shock, inappropriate shock and indeterminate.
Findings - in the 5 years examined and after exclusion of uninterpretable events there was 381 shocks from 158 specific events to review. The review of these events showed the following: appropriate shocks N=219 (57% of total), inappropriate shocks N=113 (30% of total), indeterminate shocks 49 (13% of total).
Take home messages/commentary:
- Does the study address a relevant question?
Yes. It is helpful for us to know if there is room for improvement in assessment and management of paediatric cardiac arrest, specifically the determination of whether a rhythm is shockable or not. Myocardial stunning and the conversion of a non-shockable rhythm into VF are potential complications of such an error.
- Is there any research on a similar question?
According to the study there is no such information on paediatric practice, there is however data on adult IHCA which has shown similar rates of inappropriate shock delivery.
- What are the strengths of the study?
Multicenter, international and a clinically relevant question.
- What are the limitations of the study?
Retrospective data gathering. Study relies on two clinicians to make a decision about appropriate vs inappropriate shocks which could introduce bias. Some data lost due to uninterpretable (artifact) rhythm strips (37 events excluded). No mention of clinician seniority in terms of the person deciding to shock or not shock the patients.
- Is the study applicable to our practice or population?
Yes. However, the majority of the data (88% of all shocks delivered) came from the ICU or emergency department. This environment may differ from a theatre environment, in terms of likely causes of arrest and number of senior clinicians likely to be present.