Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

Monique M Gardner¹, David A Hehir², Ron W Reeder³, Tageldin Ahmed⁴, Michael J Bell⁵, Robert A Berg², Robert Bishop⁶, Matthew Bochkoris⁷, Candice Burns⁸, Joseph A Carcillo⁷, Todd C Carpenter⁶, J Michael Dean³, J Wesley Diddle², Myke Federman⁹, Richard Fernandez¹⁰, Ericka L Fink⁷, Deborah Franzon¹¹, Aisha H Frazier¹², Stuart H Friess¹³, Kathryn Graham², Mark Hall¹⁰, Monica L Harding³, Christopher M Horvat⁷, Leanna L Huard⁹, Tensing Maa¹⁰, Arushi Manga¹³, Patrick S McQuillen¹¹, Kathleen L Meert⁴, Ryan W Morgan², Peter M Mourani¹⁴, Vinay M Nadkarni², Maryam Y Naim², Daniel Notterman¹⁵, Murray M Pollack⁵, Anil Sapru⁹, Carleen Schneiter⁶, Matthew P Sharron⁵, Neeraj Srivastava⁹, Bradley Tilford⁴, Shirley Viteri¹⁶, David Wessel⁵, Heather A Wolfe², Andrew R Yates¹⁰, Athena F Zuppa², Robert M Sutton², Alexis A Topjian²

Affiliations

¹ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA. gardnerm@chop.edu.
² Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
³ Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
⁴ Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
⁵ Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
⁶ Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
⁷ Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
⁸ Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA.
⁹ Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA.
¹⁰ Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
¹¹ Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
¹² Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA.
¹³ Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
¹⁴ Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
¹⁵ Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
¹⁶ Department of Pediatrics, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA.

PMID: 37805481
PMCID: PMC10559632
DOI: 10.1186/s13054-023-04662-9

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

Monique M Gardner et al. Crit Care. 2023.

. 2023 Oct 7;27(1):388.

doi: 10.1186/s13054-023-04662-9.

Authors

Affiliations

¹ Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA. gardnerm@chop.edu.
² Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
³ Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
⁴ Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
⁵ Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
⁶ Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
⁷ Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
⁸ Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA.
⁹ Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA.
¹⁰ Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
¹¹ Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
¹² Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA.
¹³ Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
¹⁴ Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
¹⁵ Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
¹⁶ Department of Pediatrics, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA.

PMID: 37805481
PMCID: PMC10559632
DOI: 10.1186/s13054-023-04662-9

Abstract

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-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

Methods: We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

Results: Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

Conclusions: Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.

Keywords: Blood pressure; Cardiopulmonary resuscitation; Hypotension; Infant; Neonatal; Outcomes; Pediatric; Post-cardiac arrest.

PubMed Disclaimer

Conflict of interest statement

Drs. Reeder’s, Carcillo’s, Carpenter’s, Dean’s, Fink’s, Frazier’s, Friess’, Hall’s, Manga’s, Morgan’s, Mourani’s, Nadkarni’s, Naim’s, Palmer’s, Pollack’s, Wessel’s, Wolfe’s, Yates’, Zuppa’s, Sutton’s, and Meert’s institutions received funding from the National Institutes of Health (NIH). Drs. Reeder, Berg, Carcillo, Carpenter, Dean, Fink, Frazier, Friess, Hall, Horvat, Maa, McQuillen, Meert, Morgan, Mourani, Nadkarni, Naim, Pollack, Wessel, Wolfe, Yates, and Zuppa received support for article research from the NIH. Dr. Berg’s institution received funding from the National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network grant and the National Heart, Lung, and Blood Institute (NHLBI) ICU-RESUS trial grant. Dr. Fink’s institution received funding from the Neurocritical Care Society; she received funding from the American Board of Pediatrics and the Child Neurology Society. Dr. Friess received funding from an expert witness testimony. Dr. Hall received funding from Abbvie, La Jolla Pharmaceuticals, and Kiadis. Drs. Horvat, Maa, and McQuillen’s institutions received funding from the NICHD. Dr. Horvat’s institution received funding from the National Institute of Neurological Disorders and Stroke. Dr. Maa’s institution received funding from the NHLBI. Dr. Mourani disclosed the off-label product use of sodium bicarbonate. Dr. Pollack disclosed work for hire. Dr. Wolfe received funding from The Debriefing Academy and Zoll. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

**Fig. 2**
Splines of the association of age-, sex-, and height-adjusted systolic (Panel A) and diastolic (Panel B) blood pressure percentiles at 0–6 h post-arrest by survival to hospital discharge with favorable neurologic outcome controlling for pre-arrest hypotension and illness category. Light blue boundaries represent 95% confidence intervals. Dashed line represents identified blood pressure threshold

See this image and copyright information in PMC

References

1. Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J, Grossestreuer AV, et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12(7):e005580. doi: 10.1161/CIRCOUTCOMES.119.005580. - DOI - PMC - PubMed
1. Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK, Donnino MW, et al. Trends in survival after pediatric in-hospital cardiac arrest in the United States. Circulation. 2019;140(17):1398–1408. doi: 10.1161/CIRCULATIONAHA.119.041667. - DOI - PMC - PubMed
1. Topjian AA, De Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, et al. Pediatric post-cardiac arrest care: a scientific statement from the American Heart Association. Circulation. 2019;140(6):e194–e233. doi: 10.1161/CIR.0000000000000697. - DOI - PubMed
1. Laverriere EK, Polansky M, French B, Nadkarni VM, Berg RA, Topjian AA. Association of duration of hypotension with survival after pediatric cardiac arrest. Pediatr Crit Care Med. 2020;21(2):143–149. doi: 10.1097/PCC.0000000000002119. - DOI - PubMed
1. Rosner B, Cook N, Portman R, Daniels S, Falkner B. Determination of blood pressure percentiles in normal-weight children: some methodological issues. Am J Epidemiol. 2008;167(6):653–666. doi: 10.1093/aje/kwm348. - DOI - PubMed

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

Affiliations

Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

MeSH terms

Associated data

Grants and funding

LinkOut - more resources

Full Text Sources

Medical