Caution for Calcium Use During Pediatric CPR: Do Selected Resuscitation Scenarios Benefit?

First Author(s)

• KC

  Katherine Cashen, DO

  Pediatric Cardiac Intensive Care
  DMC Childrens Hospital of Michigan
  Durham, North Carolina

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• KM

  Kathleen Meert, MD, FCCM (she/her/hers)

  Professor and Chairman of Pediatrics
  Children's Hospital of Michigan
  Detroit, Michigan, United States

  Disclosure information not submitted.
• RR

  Ron Reeder, PhD

  Associate Professor
  University of Utah, United States

  Disclosure information not submitted.
• RB

  Robert Berg, MD, MCCM (he/him/his)

  Division Chief, Pediatric Critical Care Medicine
  Children's Hospital of Philadelphia
  Merion Station, Pennsylvania, United States

  Disclosure information not submitted.
• KC

  Kellimarie Cooper, BSE

  CHOP Research Institute Resuscitation Science Clinical Program Member
  Children's Hospital of Philadelphia, United States

  Disclosure information not submitted.
• JD

  John Wesley Diddle, MD

  Assistant Professor of Pediatrics
  Childrens National Health Systems, United States

  Disclosure information not submitted.
• KG

  Kathryn Graham, BA, MLAS

  Research Coordinator
  The Children's Hospital of Philadelphia, United States

  Disclosure information not submitted.
• 

  Christopher Horvat, MD, MHA

  Children's Hospital of Pittsburgh of UPMC
  Pittsburgh, Pennsylvania

  Disclosure information not submitted.
• TK

  Theresa Kirkpatrick, MSN, CNS

  Clinical Nurse Specialist
  Mattell Childrens Hospital/UCLA, United States

  Disclosure information not submitted.
• RM

  Ryan Morgan, MD, MTR

  Assistant Professor of Anesthesia, Critical Care, & Pediatrics
  Children's Hospital of Philadelphia
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• 

  Vinay Nadkarni, MD, MS, FCCM (he/him/his)

  Professor, Anesthesiology, Critical Care and Pediatrics
  University of Pennsylvania Perelman School of Medicine, CHOP
  Media, Pennsylvania, United States

  Disclosure information not submitted.
• KP

  Kent Page, Mstat

  Biostatistician
  University of Utah, United States

  Disclosure information not submitted.
• QD

  Qunibi Danna, MD

  Assistant Professor of Pediatrics
  Nationwide Children's Hospital/The Ohio State University, United States

  Disclosure information not submitted.
• HW

  Heather Wolfe, MD,

  Pediatric Critical Care Attending Physician
  Children's Hospital of Philadelphia
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• AY

  Andrew Yates, MD

  Associate Professor of Pediatrics
  Nationwide Children's Hospital, United States

  Disclosure information not submitted.
• 

  Robert Sutton, MD, FCCM

  Professor of Anesthesia, Critical Care, & Pediatrics
  Children's Hospital of Philadelphia
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.

Title: Caution for Calcium use during pediatric CPR: Are there select resuscitation scenarios that benefit?

Introduction:
Calcium is frequently used during pediatric in-hospital cardiac arrest (p-IHCA) despite studies associating calcium use with no benefit or potential harm. Previous work could not evaluate specific subgroup populations where clinical benefit of calcium is observed anecdotally at the bedside. Our primary objective was to evaluate the association between calcium use and outcomes among specific subgroup populations hypothesized to have clinical benefit.

Methods:
Included were children ≤18 years old and ≥37 weeks corrected gestational age who received any duration of chest compressions admitted to one of 18 ICUs of The ICU-RESUScitation Project (NCT028374497), a prospective, multicenter, cluster randomized interventional trial. In this secondary analysis, detailed patient and event characteristics, pre-arrest laboratory values (-2 to -6 hours prior to IHCA), and congenital heart disease classification information were available. In a propensity score weighted cohort, the relationship between calcium use and outcomes was assessed in subjects with: 1) documented hyperkalemia ( >6 mmol/L) 2) cardiac surgery the day of arrest 3) sepsis 4) renal insufficiency and 5) specific cardiac diagnoses hypothesized as “calcium avid” (interrupted aortic arch, tetralogy of Fallot, or truncus arteriosus). The primary outcome was ROSC.

Results:
Of 1100 CPR events, average age was 3.7 years; ROSC was achieved in 773 (70%); 450 (41%) had calcium use. Among the weighted cohort, calcium use was not associated with ROSC (aOR:1.06, CI95 0.81–1.39, p=0.7), but was associated with lower survival to hospital discharge (aOR:0.73; CI95 0.56–0.96, p=0.02.) Among pre-specified subgroups, calcium use compared to no calcium use was associated with significantly higher rates of ROSC only in patients with sepsis (aOR:1.97, CI95 1.07–3.66, p=0.03) and “calcium-avid” heart disease (aOR:3.16, CI95 1.36–7.52, p< 0.01), and was not associated with improved survival to hospital discharge in any subgroup.

Conclusion:
In this multicenter cohort study of p-IHCA, calcium use was common and was associated with lower rates of survival to hospital discharge among all patients. In prespecified subgroup analyses of patients with sepsis or select congenital heart disease diagnoses, calcium use was associated with higher rates of ROSC, but not survival.