SCCM Resource Library-57-Risk Factors and Outcomes for Recurrent Pediatric In-Hospital Cardiac Arrest

Video Transcription

Hi, my name is Maria Frazier and I'm one of the Pediatric ICU Fellows at Cincinnati Children's Hospital Center. Thank you for attending my talk today on risk factors and outcomes  for current pediatric in-hospital cardiac arrest.  The Pediarescue Collaborative is supported by a research grant from Stoll Medical.  First, a little bit of background on what we will discuss. Pediatric in-hospital cardiac arrests occur an average of 15,000 times a year in the United States, and survival of  hospital discharge is low at 38%. We know that recurrent in-hospital cardiac arrests increase morbidity and mortality, but there is limited knowledge around what makes a patient  more likely to have a recurrent arrest. There have been a couple of studies that have done  secondary analysis on risk factors for recurrent cardiac arrests. The first was an adult study.  There were over 23,000 patients who experienced recurrent cardiac arrests. Their survival of hospital discharge was only 12.7% compared to 22.1% in the 165,000 patients with only  a primary arrest. This study examined some pre-arrest risk factors and showed that certain pre-existing conditions including hypotension, respiratory insufficiency, renal failure,  hepatic insufficiency, metabolic abnormalities, and sepsis increase a patient's risk of a recurrent arrest. In pediatric patients, a study by Gupta et al. showed that overall  survival to hospital discharge was 51% in a cardiac intensive care unit population.  The survival was lower in the recurrent versus a single arrest group at 41 versus 53%. The study  also did a secondary analysis on risk factors for recurrent arrests. The pre-arrest risk factors  were similar to the prior study with risk factors including respiratory insufficiency, arrhythmias, metabolic abnormalities, and vasoactive effusion. Of note, the median age  for this study was only four months and it was isolated to cardiac patients only. Therefore, it is not representative of the broader pediatric population.  Finally, this paper by Dr. Brown and colleagues at Seattle Children's examined patients who had  a recurrent in-hospital arrest and risk factors for mortality after that recurrent arrest. This  paper is different from the other two studies as it is limited in population to recurrent arrest  patients only and sought to determine risk factors for mortality. Pre-arrest characteristics of intubation, lower pH, higher lactate, and higher comorbidities along with post-arrest  characteristics of lower pH and higher lactate were associated with a higher mortality.  In addition, patients with an initial rhythm of V-tach or V-fib had a higher survival rate than patients with only one or with other rhythms.  Which brings us to the point that no study has examined risk factors for recurrent arrest in  the entire pediatric population and their outcomes compared to patients with only one arrest.  The objective of our study was to identify patient characteristics during an index or first in-hospital cardiac arrest associated with an increased risk for recurrent in-hospital  cardiac arrest and to compare their outcomes to those with only one arrest.  To do this, we performed a retrospective cohort study using data from the PD Rescue Collaborative. This collaborative collects cardiac arrest data from over 45 children's hospitals  and it's based out of Children's Hospital of Philadelphia. We excluded patients in the NICU  and those who went on ECMO after their initial arrests. We analyzed categorical variables via  chi-square test and continuous variables via rank-sum testing. We did an adjusted analysis  on the outcomes data with Bonferroni correction. We did further analysis and did logistic regression on the outcomes data to adjust for age and number of pre-existing conditions.  Risk factors we examined were the following, age, gender, race, pre-existing conditions,  pre-arrest PCPC score, location and duration of arrest. We examined outcomes including survival to ICU or hospital discharge and discharge with good neurological outcomes.  Here's our breakdown. You can see we had 504 patients with only one arrest and 103 patients  with more than one arrest. We found that children who experienced a recurrent arrest were more likely  to be older with a median age of 1.9 years as compared to those with a single index arrest only with a median age of 1. There was no statistically significant difference in sex,  race, or pre-arrest PCPC score between the groups.  Patients with a recurrent arrest were more likely to have a congenital malformation, metabolic or electrolyte abnormality, and or septicemia prior to their index arrest.  Furthermore, patients with recurrent arrests had more pre-existing conditions prior to their index  arrest. There was no difference seen in cardiac malformation, although there was a trend towards  more cardiac patients in the no recurrent arrest group. In addition, there was no difference in  hypotension, hypoperfusion, trauma, pneumonia, renal insufficiency, respiratory insufficiency,  and or genetic abnormalities. There was no difference seen in location of arrest or duration  of CPR. Here are unaddressed outcomes. You can see that patients with recurrent arrests had  lower survival to ICU and hospital discharge at 24.3 percent and 22.3 percent respectively  as compared to those with only a single arrest at 62.5 and 58.7 percent. In addition, patients with  recurrent arrests had worse neurological outcomes than survivors. All these results were statistically  significant. Given that both age and number of pre-existing conditions had a statistically  significant difference between the groups, we use logistic regression to examine the impact of  recurrent arrests on survival after adjusting for age and number of pre-existing conditions.  There remained a significant impact of recurrent cardiac arrests on survival to ICU discharge and on survival to hospital discharge following this adjustment.  In conclusion, there are pre-arrest risk factors that are associated with recurrent arrests and recurrent in-hospital cardiac arrests are associated with worse survival in a general  pediatric population. Patients who were older and with more comorbidities were more likely to have  a recurrent arrest. Our recurrent arrest rate was 17 percent which is similar to the pediatric study  of CICU patients who had a recurrent arrest rate of 18 percent. It is higher than the adult study  which showed a recurrent arrest rate of 12 percent. In addition, our survival hospital discharge of 43 percent is consistent with the guidelines pediatric CICU study whose hospital  discharge for recurrent in-hospital cardiac arrests was 41 percent. We demonstrated that patients with recurrent in-hospital cardiac arrests had worse survival even after adjusting  for both age and number of comorbidities. The strength of our study is that it's from multiple  centers improving generalizability. The weaknesses are that there was only 103 recurrent arrests to analyze. There was no long-term follow-up with the patient.  Moving forward, we plan to analyze the fetal data from the code events to assess the impact of CPR  quality on recurrent arrests. We will also plan to re-examine our findings regarding the impact  of recurrent arrests on survival using propensity matching. Thank you for your time to the  collaborative and most importantly to Maya DeWine who was my mentor on this project. I will now take any questions you guys have. Thanks again.

Video Summary

Pediatric in-hospital cardiac arrests occur about 15,000 times a year in the U.S. and have a low survival rate. Recurrent arrests have even lower survival rates, but there is limited research on the risk factors for recurrent arrest in pediatric patients. Previous studies on adults and isolated cardiac patients have identified pre-arrest risk factors such as hypotension and respiratory insufficiency. A study was conducted on a general pediatric population from multiple centers to identify risk factors for recurrent arrest and compare outcomes to patients with only one arrest. The study found that older age and more comorbidities were associated with recurrent arrest and worse survival rates. The study's strength lies in its multi-center approach, but it had limitations in terms of a small sample size and lack of long-term follow-up. Future plans include analyzing fetal data and re-examining the impact of recurrent arrest on survival using propensity matching.

Asset Subtitle

Pediatrics, Resuscitation, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Maria Frazier

Introduction/Hypothesis: Recurrent in-hospital cardiac arrest (IHCA) is associated with morbidity and mortality in children, yet little is known about risk factors. The objective was to identify the patient and event characteristics during an index(first) IHCA associated with an increased risk for recurrent IHCA.

Methods: Retrospective cohort of consecutive patients reported to the Pediatric Resuscitation Quality Collaborative with age â‰¤18-years and IHCA with CPR for >1 minute. Patients were excluded for Neonatal ICU location, if died during index IHCA arrest, or if placed on ECMO during index IHCA. Recurrent arrest was defined as â‰¥2 IHCA within the same hospitalization. Categorical variables were expressed as percentages and compared via chi square test. Continuous variables were expressed as medians with interquartile ranges (IQR) and compared via rank sum test. Outcome analysis was adjusted with Bonferroni correction.

Results: From July 2015-May 2020, 80/506 (16%) IHCA patients met recurrent IHCA inclusion criteria. Patient Factors: Recurrent IHCA patients were older with a median age of 4.9 years (IQR:0.6-9.1) vs. 0.9 years (IQR:0.3-5); p=0.01, and more likely to have pre-existing conditions including congenital malformation (28% vs.16%; p=0.02) and metabolic electrolyte abnormalities (30% vs. 15%; p=0.0001). Event Factors: The median duration of the index CPR event was shorter for those with a recurrent arrest, 5 minutes, (IQR:3-14) vs. 8 minutes (IQR:4-21); p=0.05. Location of arrest, immediate cause of CPR, and medications administered index CPR were not significantly different. Outcomes: Recurrent IHCA was associated with worse survival to ICU discharge (34% vs. 65%, p=0.0004), worse survival to hospital discharge (32% vs. 60%, p=0.0004), and worse neurologic outcome defined as PCPC Ëƒ2 (61% vs. 32% p=0.024).

Conclusions: Several patient and event factors (older age, pre-existing conditions, shorter duration of index event) were associated with risk for recurrent cardiac arrest. Recurrent IHCA was consistently associated with worse survival outcomes. Better understanding of modifiable risk factors and mitigation of recurrent IHCA may inform interventions that prevent recurrent IHCA and improve patient outcomes.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Resuscitation

Knowledge Level Advanced

Membership Level Select

Tag Cardiac Arrest

Year 2021

Keywords

Pediatric in-hospital cardiac arrests

recurrent arrest risk factors

survival rates

multi-center approach

long-term follow-up

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.