Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis

Abstract

Importance: Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population.

Objective: To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU.

Data sources: A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021.

Study selection: Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y).

Data extraction and synthesis: Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality.

Main outcomes and measures: Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC).

Results: Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds.

Conclusions and relevance: This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.

Figure 1.. Flowchart of the Study Selection Process

CA indicates cardiac arrest; ECPR, extracorporeal cardiopulmonary resuscitation; ICU, intensive care unit.

Figure 2.. Trend in Incidence of In-Hospital Cardiac Arrest (IHCA) Over Time by Metaregression

The incidence of IHCA in pediatric patients with cardiac disease in the intensive care unit significantly decreased in the last 20 years (P for trend < .001). The model was adjusted for type of study (registry-based vs nonregistry-based) and diagnostic category (surgical vs general cardiac).

Figure 3.. Trend in In-Hospital Mortality After In-Hospital Cardiac Arrest (IHCA) Over Time by Metaregression

The in-hospital mortality rate after IHCA in pediatric patients with cardiac disease in the intensive care unit significantly decreased in the last 20 years (P for trend < .001). The model was adjusted for diagnostic category (surgical vs general cardiac).