Vinay Nadkarni

The Children's Hospital of Philadelphia | CHOP · Department of Anesthesia and Critical Care Medicine

Background: Resuscitation with chest compressions and positive pressure ventilation in Bidirectional Glenn (BDG) or Fontan physiology may compromise passive venous return and accentuate neurologic injury. We hypothesized that arterial pressure and survival would be better in BDG than Fontan patients. Methods: Secondary analyses of the Pediatric...

Background: Tracheal intubation (TI)-associated cardiac arrest (TI-CA) occurs in 1.7% of pediatric ICU TIs. Our objective was to evaluate resuscitation characteristics and outcomes between cardiac arrest patients with and without TI-CA. Methods: Secondary analysis of cardiac arrest patients in both ICU-RESUS trial and ancillary CPR-NOVA study. T...

Importance Patients with underlying cardiac disease form a considerable proportion of pediatric patients who experience in-hospital cardiac arrest. In pediatric patients after cardiac surgery, CPR with abdominal compressions alone (AC-CPR) may provide an alternative to standard chest compression CPR (S-CPR) with additional procedural and physiologi...

Background/purpose Sepsis is a leading cause of morbidity, mortality and healthcare utilisation for children worldwide, particularly in resource-limited regions. In Kumasi, Ghana, organ system failure and mortality in children who present to the emergency department (ED) with symptoms of sepsis are often due to late presentation and lack of recogni...

Background: Half of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes i...

Objectives Early shock reversal is crucial to improve patient outcomes. Capillary refill time (CRT) is clinically important to identify and monitor shock in children but has issues with inconsistency. To minimize inconsistency, we evaluated a CRT monitoring system using an automated compression device. Our objective was to determine proper compress...

Objectives Data to support epinephrine dosing intervals during cardiopulmonary resuscitation (CPR) are conflicting. The objective of this study was to evaluate the association between epinephrine dosing intervals and outcomes. We hypothesized that dosing intervals less than 3 minutes would be associated with improved neurologic survival compared wi...

Objective Quantify hypotension burden using high-resolution continuous arterial blood pressure (ABP) data and determine its association with outcome after pediatric cardiac arrest. Design Retrospective observational study. Setting Academic PICU. Patients Children 18 years old or younger admitted with in-of-hospital or out-of-hospital cardiac arr...

Objective We aimed to investigate the association of recent team leader simulation training (<6 months) and years of clinical experience (≥4 years) with chest compression quality during in-hospital cardiac arrest (IHCA). Methods This cohort study of IHCA in four Danish hospitals included cases with data on chest compression quality and team leader...

BACKGROUND The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with wor...

Rationale: Adult and pediatric studies provide conflicting data regarding whether post-cardiac arrest hypoxemia, hyperoxemia, hypercapnia, and/or hypocapnia are associated with worse outcomes. Objectives: We sought to determine whether postarrest hypoxemia or postarrest hyperoxemia is associated with lower rates of survival to hospital discharge, c...

Objectives To determine if near-infrared spectroscopy measuring cerebral regional oxygen saturation (crS o 2 ) during cardiopulmonary resuscitation is associated with return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD) in children. Design Multicenter, observational study. Setting Three hospitals in the pediatric Resu...

The true global burden of paediatric critical illness remains unknown. Studies on children with life-threatening conditions are hindered by the absence of a common definition for acute paediatric critical illness (DEFCRIT) that outlines components and attributes of critical illness and does not depend on local capacity to provide critical care. We...

Objectives Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o 2 (ET co 2 ) are associated with survival to hospital discharge with favorable neurolog...

Background Sepsis is a highly heterogeneous syndrome, which has hindered the development of effective therapies. This has prompted investigators to develop a precision medicine approach aimed at identifying biologically homogenous subgroups of patients with septic shock and critical illnesses. Transcriptomic analysis can identify subclasses derived...

Background Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is...

Introduction: Survival and outcomes after cardiac arrest (CA) depend largely on the effectiveness of cardiopulmonary resuscitation (CPR). Traditional invasive methods of monitoring CPR can be challenging out-of-hospital and are lacking in more than 50% of in-hospital pediatric CA. Regional oxygen saturation (rSO 2 ) monitoring with Near Infrared Sp...

Introduction: Though epinephrine is recommended during CPR for children with bradycardia with poor perfusion, a registry study identified an association between epinephrine administration and worse outcomes. Our objective was to use granular data from the ICU-RESUScitation (ICU-RESUS) trial, including markers of illness severity not available in re...

Introduction: Defibrillation with an automated external defibrillator (AED) is critical in the chain of survival following a cardiac arrest caused by pulseless ventricular tachycardia and ventricular fibrillation. However, in 2022 the International Liaison Committee on Resuscitation could not make a recommendation for or against the use of AEDs in...

Background: Pediatric resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO 2 ) as an indicator of CPR quality but note that “specific values to guide therapy have not been established in children.” Aims & Hypotheses: We aimed to determine the association of ETCO 2 during CPR with pediatric IHCA outcomes. We hypothesized that...

Background: During cardiopulmonary resuscitation (CPR), diastolic blood pressure (DBP) is a key driver of coronary perfusion pressure and thereby, blood flow during CPR. Although resuscitation guidelines advise measuring DBP as an indicator of CPR quality, the need for an invasive arterial catheter to measure DBP limits scope of patients for whom a...

Introduction: Racial, ethnic, and socioeconomic disparities in pediatric out-of-hospital cardiac arrest (OHCA) exist; however, pediatric OHCA incidence and survival outcomes among race, ethnicity, and socioeconomic status (SES) are unknown. We evaluated the incidence and outcomes of pediatric OHCA among race, ethnicity, and SES, hypothesizing that...

Background: Supported by laboratory and clinical investigations of adult cardiopulmonary arrest, resuscitation guidelines recommend monitoring end-tidal carbon dioxide (ETCO2) as an indicator of CPR quality but note that "specific values to guide therapy have not been established in children." Methods: This prospective observational cohort study wa...

Objectives Extremes of patient body mass index are associated with difficult intubation and increased morbidity in adults. We aimed to determine the association between being underweight or obese with adverse airway outcomes, including adverse tracheal intubation (TI)-associated events (TIAEs) and/or severe peri-intubation hypoxemia (pulse oximetry...

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-a...

Objectives To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease. Design Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016–2021). Setting Eigh...

Aim: To evaluate associations between characteristics of simulated point-of-care cardiopulmonary resuscitation (CPR) training with simulated and actual intensive care unit (ICU) CPR performance, and with outcomes of children after in-hospital cardiac arrest. Methods: This is a pre-specified secondary analysis of the ICU-RESUScitation Project; a...

Background Current pediatric cardiac arrest guidelines recommend depressing the chest by one‐third anterior–posterior diameter (APD), which is presumed to equate to absolute age‐specific chest compression depth targets (4 cm for infants and 5 cm for children). However, no clinical studies during pediatric cardiac arrest have validated this presumpt...

Background: Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prev...

Objectives: To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA). Design: Retrospective cohort study. Setting: An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q]. Patients: All IHCA events from 2015 to 2020 from the pediRES-Q Colla...

Introduction: Contemporary rates of survival after pediatric in-hospital cardiac arrest (IHCA) and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and rates of survival after IHCA inc...

Background Epinephrine is provided during cardiopulmonary resuscitation (CPR) to increase systemic vascular resistance and generate higher diastolic blood pressure (DBP) to improve coronary perfusion and attain return of spontaneous circulation (ROSC). The DBP response to epinephrine during pediatric CPR and its association with outcomes have not b...

Trauma is a global challenge and India has one of the highest trauma deaths in the world. Despite United Nations target to halve the global number of deaths and injuries from road traffic crashes by 2030, death tolls from Road Traffic Injuries (RTI) rising in India. In pediatric age groups, falls from height add to the burden of trauma. Uncontrolle...

Objectives: To provide an updated review of the literature on nonpulmonary treatments for pediatric acute respiratory distress syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference. Data sources: MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Study selection: Searches were limited to children wi...

Objectives: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. Design: International consensus conference serie...

Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was...

Aim: To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit. Methods: This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Child...

Objectives: Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter...

Introduction: Duration of cardiopulmonary resuscitation (CPR) in patients without return of spontaneous circulation (ROSC) is a proxy measure for the persistence of intense resuscitation efforts. We evaluated the association between patient and event characteristics and resuscitation duration among children who did not survive a CPR event. Methods:...

Introduction: Approximately 15,200 children suffer an in-hospital cardiac arrest (IHCA) annually, and 10-20% will have ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT). Timely defibrillation is critical for shockable rhythms, however current data are lacking on outcomes when > 1 shock is required for termination of VF/pVT. Met...

Introduction: Racial disparities for in-hospital cardiac arrest (IHCA) outcomes exist. However, whether these are associated with medical emergency team (MET) activation prior to IHCA remain unknown. We aimed to evaluate the association between race and MET activation among patients with physiologic abnormalities (modified early warning score [MEWS...

Introduction: Contemporary rates of survival after pediatric in-hospital cardiac arrest (IHCA) and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that (1) survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and (2) rates of survival after...

Introduction: Cerebral regional oxygen saturation (crS0 2 ) measured by near-infrared spectroscopy (NIRS) during CPR is associated with outcomes in adults, but there is limited pediatric data. Hypothesis: Median crSO 2 during pediatric in-hospital cardiac arrest (IHCA) is associated with return of spontaneous circulation (ROSC) and survival to hosp...

Introduction: Chest compression release velocity (CCRV) during chest compression (CC) recoil is understudied in pediatrics. Our objective was to characterize CCRV during pediatric in hospital cardiac arrest (IHCA). Methods: Using the PediRES-Q multicenter prospective observational cohort from 2015 to 2021, we analyzed patients <18 years who receive...

Introduction: Successful cardiopulmonary resuscitation (CPR) outcomes rely on AHA guideline compliant chest compressions (CC). Resuscitation teams struggle to achieve these CPR metrics. Cold debriefing has led to higher quality CPR and improved patient outcomes. The impact of hot debriefing (HD) on CPR quality and patient outcomes is unknown. We so...

Objectives: The primary objective was to investigate the association between clinician-reported use of end-tidal CO2 (ETCO2) or diastolic blood pressure (DBP) to monitor cardiopulmonary resuscitation (CPR) quality during pediatric in-hospital cardiac arrest (IHCA) and survival outcomes. The secondary objective was to investigate the change in use o...

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 maint...

Introduction: Children with cardiac disease have higher rates of in hospital cardiac arrest (IHCA) compared to non-cardiac disease. We aimed to determine differences in survival in children with medical and surgical cardiac compared to non-cardiac disease following IHCA and to assess whether CPR quality was different between groups. Hypothesis: We...

Objectives: Capillary refill time (CRT) to assess peripheral perfusion in children with suspected shock may be subject to poor reproducibility. Our objectives were to compare video-based and bedside CRT assessment using a standardized protocol and evaluate interrater and intrarater consistency of video-based CRT (VB-CRT) assessment. We hypothesize...

Objectives: The COVID-19 pandemic resulted in adaptations to pediatric resuscitation systems of care. The objective of this study was to determine the temporal association between the pandemic and pediatric in-hospital cardiac arrest (IHCA) process of care metrics, cardiopulmonary resuscitation (cardiopulmonary resuscitation) quality, and patient...

Simulation based training (SBT) plays a pivotal role in quality improvement and patient safety. Simulation is not only for training health care professionals but also an excellent tool for systems and facility changes which will potentially improve patient safety and ultimately outcomes. SBT is already established both as a training modality, and a...

Objectives: To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). Design: Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. Setting: Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). Patients: Ch...

Introduction Pediatric shock, especially septic shock, is a significant healthcare burden in low-income countries. Early recognition and management of shock in children improves patient outcome. Simulation-based education (SBE) for shock recognition and prompt management prepares interdisciplinary pediatric emergency teams in crisis management. COV...

Objectives: Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown. Design: Multicenter cross-sectional survey regarding institutional practices for the transition from weight-base...

Background: There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. Aim: Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubat...

Objective The effect of cardiac arrest (CA) on cerebral transcriptomics and metabolomics is unknown. We previously demonstrated hemodynamic-directed CPR (HD-CPR) improves survival with favorable neurologic outcomes versus standard CPR (Std-CPR). We hypothesized HD-CPR would preserve the cerebral transcriptome and metabolome compared to Std-CPR. De...

Objectives: To compare outcomes associated with timing-early versus late-of any neurologic dysfunction during pediatric sepsis. Design: Secondary analysis of a cross-sectional point prevalence study. Setting: A total of 128 PICUs in 26 countries. Patients: Less than 18 years with severe sepsis on 5 separate days (2013-2014). Interventions:...

Objective To characterize chest compression (CC) pause duration during the last 5 minutes of pediatric cardiopulmonary resuscitation (CPR) prior to extracorporeal-CPR (E-CPR) cannulation and the association with survival outcomes. Methods Cohort study from a resuscitation quality collaborative including pediatric E-CPR cardiac arrest events ≥10 mi...

Importance: Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. Objective: To eva...

Aim Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge. Methods Prospective, single-center observational study of cerebral oximetry using nea...

Introduction: Shockable rhythms (ventricular fibrillation [VF] and ventricular tachycardia [VT]) occur in <25% of pediatric in-hospital cardiac arrest (IHCA) events, yet the prevalence of inappropriate defibrillation attempts for non-VF/VT rhythms is unknown. We aim to describe the prevalence of inappropriate shocks across a large, multi-national p...

Introduction: Survival of adult patients with COVID-19 who had an in-hospital cardiac arrest (IHCA) are poor. Characteristics and outcomes for pediatric IHCA patients with COVID-19 are unknown. Hypothesis: We hypothesized that pediatric COVID-19 patients would have worse survival outcomes when compared to non-COVID patients. Methods: A multicenter,...

Background: This study describes a novel approach to identify diagnostic properties in an electrocardiogram (ECG) waveform to classify cardiac arrest etiologies in human patients. Through an interdependent optimization algorithm linking machine learning and signal processing, the technique allows extensive electrocardiogram analysis, retrieving phy...

Objectives Develop and evaluate a high-dimensional, data-driven model to identify patients at high risk of clinical deterioration from routinely-collected electronic health record (EHR) data. Methods In this single-center, retrospective cohort study, 488 patients with single-ventricle and shunt-dependent congenital heart disease (CHD) <6 months ol...