Timing and modes of death after pediatric out-of-hospital cardiac arrest resuscitation

Abstract

Aim: To determine the timing and modes of death of children admitted to a pediatric critical care unit (PICU) of a tertiary care center after an out-of-hospital cardiac arrest (OHCA).

Methods: This is a retrospective descriptive study at a tertiary care PICU of all consecutive patients <18 years old who received ≥1 min of chest compressions, had return of spontaneous circulation (ROSC) for ≥20 min, and were admitted to the PICU after an OHCA. Modes of death were classified as brain death (BD), withdrawal due to neurologic prognosis (W/D-neuro), withdrawal for refractory circulatory failure (W/D-RCF), and re-arrest without ROSC (RA).

Results: 191 consecutive patients were admitted to the PICU from February 2005 to May 2013 after an OHCA. Eighty-six(45%) patients died prior to discharge: BD in 47%(40/86), W/D-neuro in 34%(29/86), W/D-RCF in 10%(9/86), and RA in 9%(8/86). Time to death was longer for patients with W/D-neuro: 4 days [1, 5] and BD 4 days [1, 5](p < 0.01) as opposed to those with W/D-RCF (1 day[1, 2]) and RA(1 day[0.5, 1]). Of patients who underwent W/D-neuro, 9/29(31%) died within 3 days of PICU admission and 20/29(69%) ≥3 days. Of patients who died after W/D-neuro, 12/29(41%) received therapeutic hypothermia, 27/29(93%) underwent EEG monitoring, 21/29(72%) had a brain CT, and 13/29(45%) had a brain MRI. All MRIs showed signs of hypoxic-ischemic injury.

Conclusion: Neurologic injury was the most common mode of death post-resuscitation care OHCA after in a tertiary care center PICU. Neurologic prognostication impacts the outcome of a large proportion of patients after OHCA, and further studies are warranted to improve its reliability.

Keywords: Brain death; Cardiac arrest; Circulatory failure; Irreversible neurologic injury; Neurologic injury; Withdrawal of technological support.