Post-Arrest Favorable Neurologic Outcomes: Variability based on underlying disease. An outcomes comparison between children with medical cardiac, surgical cardiac, and noncardiac diseases after in-hos
Myron Yaster MD, Ethan Sanford MD, Shawn Jackson MD PhD, and Justin L. Lockman MD MSEd
n-hospital cardiac arrest management has changed significantly over the past 2 decades. Cardiac arrests occurring on the inpatient unit are becoming increasingly rare because of the widespread use of rapid response teams and early transfer for at risk patients to the ICU. Nevertheless, regardless of where the in-hospital arrests occur, “educational interventions aimed at early recognition of cardiac arrest and improving quality of cardiopulmonary resuscitation (CPR) have helped improve survival for all children with cardiac arrest. Real-time feedback devices, applied during CPR, that measure rate and depth of chest compressions and physiologic monitors that measure blood pressure and end-tidal carbon dioxide (ETCO2) provide an opportunity for optimizing quality of CPR with a goal of improving survival.”1-3
In today’s PAAD4 and accompanying editorial1 the authors wondered whether these real-time feedback devices would work accurately in patients with congenital heart disease, particularly those who had undergone surgery. After all, how deep can compressions be made in a patient who recently had a sternotomy? Is ETCO2 guidance for return of spontaneous circulation (ROSC) useful in patients for whom ETCO2 is low because of poor pulmonary circulation and increased dead space prior to their arrest? Federman et al. sought “to determine in a contemporary 2016–2021 cohort, differences in survival with favorable neurologic outcomes after IHCA in children with medical cardiac, surgical cardiac, and noncardiac disease, and to assess whether CPR quality differed between groups.”4
Surprisingly to me, “current literature suggests that children with CHD and acquired heart disease have higher survival following cardiac arrest compared with those with noncardiac diseases.”5 I naively thought that survival would be worse in CHD patients because children with CHD with or without surgery would be “sicker” and more hemodynamically compromised before the arrest.
I’ve asked the PAAD’s PICU Executive Council members, Drs Ethan Sanford, Shawn Jackson, and Justin Lockman to assist. Myron Yaster MD
Editorial
Thiagarajan RR. Quality of Cardiopulmonary Resuscitation in Children With Cardiac and Noncardiac Disease: Comparing Apples and Oranges? Pediatr Crit Care Med. 2024 Jan 1;25(1):72-73. doi: 10.1097/PCC.0000000000003399. Epub 2024 Jan 3. PMID: 38169337.
Original article
Federman M, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kirkpatrick T, Maa T, Maitoza LA, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Naim MY. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatr Crit Care Med. 2024 Jan 1;25(1):4-14. doi: 10.1097/PCC.0000000000003368. Epub 2023 Sep 7. PMID: 37678381.
Federman et al. carried out a secondary analysis of the ICU-RESUScitation (ICU-RESUS) project which was a multicenter prospective trial of QI training measures for pediatric cardiac arrest. The data may, then, be of better quality than prior database studies which rely on retrospective data captured from the EMR.6 The population consisted of “1,100 children with IHCA, 273 (25%) were medical cardiac, 383 (35%) were surgical cardiac, and 444 (40%) were noncardiac.”4 The authors hypothesized that the populations would exhibit similar survival characteristics to prior studies, with medical cardiac patients having the worst outcomes, surgical cardiac having the best, and children without cardiac disease somewhere in the middle. The primary outcome was survival to hospital discharge with favorable neurologic outcome assessed by Pediatric Cerebral Performance Category (PCPC).
We think the populations deserve some careful consideration, as Dr. Thiagarajan acknowledges in his editorial. First, the cardiac patients were much younger and had higher baseline PCPC scores. We also should point out that PCPC is a relatively blunt instrument for measuring neurologic outcomes. As a result, detecting differences in PCPC for infants versus older children may bias the results.
Perhaps more importantly, “the proximate hemodynamics at the time of arrest was most commonly hypotension in the surgical cardiac group and respiratory decompensation in the noncardiac group.” In other words, the underlying cause of the cardiac arrest and required interventions were quite different. Undoubtedly, most pediatric anesthesiologists have experience with brief respiratory arrest in the OR which is swiftly rescued with airway intervention. Most of these events do not result in long term morbidity or mortality. Conversely, an intubated child with refractory hypoxemia and ARDS who arrests while transitioning to the oscillator may have much lower chance of survival, and is at risk for worse neurologic outcomes due to prolonged hypoxemia before the arrest. There may be more commonalities among the cardiac groups than within the (likely heterogenous) noncardiac group, but this is hard to prove with the existing data. It is worth considering, however, that the outcomes of cardiac arrest in these populations may be biased by the differences in arrest etiology in addition to differences in monitoring or CPR quality. Nonetheless, it is certainly worthwhile assessing for differences among these factors, which is what the authors are attempting to do.
What did they find? “The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39–0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45–0.9], p = 0.01) .”4 No differences in were detected between surgical cardiac and noncardiac groups.
The differences detected among CPR characteristics were: (1) longer CPR duration for the cardiac groups, (2) lower odds of reaching target chest compression depth in the cardiac surgery group, (3) lower blood pressure and end-tidal CO2 in both cardiac groups, and (4) greater utilization of ECMO (ECPR) in both cardiac groups. CPR time may be a function of arrest cause/rescue. We suspect that poor chest compression depth for surgery patients is likely due to concerns about disruption of surgical repair, open chests, and desire to open the chest for central ECMO cannulation. More interesting may be the differences between end-tidal CO2 and diastolic blood pressure. This could be due to differences in pulmonary blood flow, but likely deserves more consideration.
Finally, outcomes of ECMO CPR (ECPR) are known to be better for children with cardiac disease. This may be due to access (open or recently opened chest), poor oxygenation during prolonged arrest in children without cardiac disease who instead have pulmonary disease, and/or shorter time to cannulation for more experienced cardiac surgeons (we note a constant discussion in many centers about which surgeons should perform ECPR).
Do these results surprise you as much as they surprised Myron? Do the worsened outcomes for children with medical cardiac disease influence your practice? What do you think? Send your responses to Myron at MYasterster@gmail.com who will post in a Friday Reader Response.
References
1. Thiagarajan RR. Quality of Cardiopulmonary Resuscitation in Children With Cardiac and Noncardiac Disease: Comparing Apples and Oranges? Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2024;25(1):72-73. (In eng). DOI: 10.1097/pcc.0000000000003399.
2. Frazier M, Dewan M, Keller-Smith R, Shoemaker J, Stewart C, Tegtmeyer K. Improving CPR Quality by Using a Real-Time Feedback Defibrillator During Pediatric Simulation Training. Pediatric emergency care 2022;38(2):e993-e996. (In eng). DOI: 10.1097/pec.0000000000002370.
3. Sutton RM, French B, Meaney PA, et al. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Resuscitation 2016;106:76-82. (In eng). DOI: 10.1016/j.resuscitation.2016.06.018.
4. Federman M, Sutton RM, Reeder RW, et al. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 2024;25(1):4-14. (In eng). DOI: 10.1097/pcc.0000000000003368.
5. Sperotto F, Daverio M, Amigoni A, et al. Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis. JAMA network open 2023;6(2):e2256178-e2256178. DOI: 10.1001/jamanetworkopen.2022.56178.
6. Sutton RM, Wolfe HA, Reeder RW, et al. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. Jama 2022;327(10):934-945. (In eng). DOI: 10.1001/jama.2022.1738.