Prearrest vital sign abnormalities are associated with adverse outcomes in pediatric ICU cardiac arrest: a get with the guidelines-resuscitation analysis

Abstract

Aim: We aimed to quantitatively describe vital sign abnormalities prior to pediatric IHCA and evaluate whether the severity of abnormalities was independently associated with survival.

Methods: In a retrospective cohort study using the American Heart Association's Get with The Guidelines-Resuscitation® registry, children with ≥1 min of cardiopulmonary resuscitation (CPR) in an Intensive Care Unit (ICU) from 2007 to 2022 with prearrest vital signs were included. Vital signs most proximate to CPR (10-120 min prior) were classified as abnormal (HR or RR >95th, SBP or DBP <5th percentile for age). Multivariable regression adjusted for age, illness category, prearrest conditions, and prearrest interventions assessed the associations between vital sign abnormalities and outcomes (primary: survival to hospital discharge, secondary: return of spontaneous circulation [ROSC]).

Results: Of 2875 IHCA patients meeting inclusion criteria, 1790 (62.3 %) had at least one abnormal vital sign. Patients with vital sign abnormalities were older, had non-surgical illness categories, and higher prevalence of prearrest illnesses and interventions. Low SBP (<5%) was the vital sign with the lowest odds of survival to hospital discharge (aOR 0.56 [95 %CI 0.46-0.68], p < 0.01) and ROSC (aOR 0.63 [95 %CI 0.54-0.73], p < 0.01). There was a stepwise decrease in the adjusted odds of survival for each additional abnormal vital sign (1 vs 0: aOR 0.62 [95 %CI 0.51-0.76], p < 0.01; 2 vs 1: 0.72 [95 %CI 0.53-0.97] p = 0.03; 3 vs 2: 0.53 [95 %CI 0.33-0.86] p < 0.01).

Conclusions: Prearrest vital sign abnormalities are common in pediatric ICU IHCA and independently associated with worse outcomes, emphasizing the need for prompt detection and intervention to improve outcomes.

Keywords: Cardiac arrest; Cardiac intensive care unit; Pediatric intensive care unit; Pediatrics; Physiology; Vital signs.

Fig. 1 –. Study Cohort Flowchart: Application of Inclusion and Exclusion Criteria.

Application of inclusion and exclusion criteria to arrive at final study cohort of 2875 events. * valid defined as vital signs in physiologic range: heart rate >1 and <300 beats per minute, respiratory rate >1 and <150 breaths per minute, systolic blood pressure >1 and <300 mmHg, diastolic blood pressure >1 and <200 mmHg. ** complete set defined as having all four vital sign values (heart rate, respiratory rate, systolic blood pressure, and diastolic blood pressure) recorded at the same time. *** from sites with low vital sign documentation rates defined as sites at which less than 50 % of eligible In-hospital cardiac arrest (IHCA) cases per year had documented vital signs.

Fig. 2 –. Association between presence of abnormal vital signs with outcomes.

Forrest plots (A and C) show the association between abnormal vital sign exposures for survival (A) and ROSC (C). Adjusted odds ratios (aOR) account for age, illness category, prearrest conditions, and ICU intervention. Error bars represent the 95 % confidence interval. P-values report the results of the adjusted odds ratios. Panels B and D show the association between the number of abnormal vital signs and predicted probability of survival (B) and ROSC (D) unadjusted and after adjustment for age, illness category, prearrest conditions, and ICU intervention. Error bars represent the 95 % confidence interval. * Indicates a significant difference between that number of abnormal vital signs and the prior group (e.g., 1 vs 0 abnormal vital signs, 2 vs 1, or 3 vs 2) for the adjusted model. HR = Heart rate (abnormal defined as >95 % for age). RR = Respiratory rate (abnormal defined as >95 % for age). SBP = Systolic blood pressure (abnormal defined as <5 % for age), DBP = Diastolic blood pressure (abnormal defined as <5 % for age). Pulse pressure = Difference between SBP and DBP (abnormal defined as <20 mmHg).

Fig. 3 –. Association between vital signs grouped by percentiles of age-based normalized values and outcomes.

Predicted probability of survival (top row) and ROSC (bottom row) across age-based percentile categories for each vital sign. Predicted probabilities estimated from a multivariable logistic regression adjusted for age, illness category, prearrest conditions, and ICU interventions. Survival = survival to hospital discharge. ROSC = sustained return of spontaneous circulation (>20 min after arrest). * Denotes a significant difference from the reference group (highest probability of outcome) using a Bonferroni corrected significance threshold to account for multiple comparisons (0.05/13).