Multicenter cohort study of in-hospital pediatric cardiac arrest

Abstract

Objectives: 1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest.

Design: Retrospective cohort study.

Setting: Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network.

Patients: Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for >1 min, and had a return of circulation for >20 mins.

Interventions: None.

Measurements and main results: A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness.

Conclusions: Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.

Figure 1. Patient Mortality By Number of Epinephrine Doses Received

Data are unadjusted and represent a basic summary of mortality by number of epinephrine doses. The solid line includes all patients. The dashed line excludes patients placed on ECMO in the 12 hours following arrest.

Figure 2. Probability of Death Based on pH Values

Predicted probabilities are based on logistic regression Model 2 (including variables prior to, during, and up to 12 hours after cardiac arrest). The predicted probabilities are based on an "average" cardiac arrest patient with median age (0.9 years) and values for all other variables based on most frequently observed in population, ie, male with initial arrest rhythm of bradycardia, calcium administered during CPR, and both pupils responsive during 12 hours post arrest.