SCCM Resource Library-Diastolic Blood Pressure Threshold During Pediatric CPR and Outcomes: A Multicenter Validation Study

Video Transcription

Hello, I'm Bob Berg and I'm going to be presenting this multicenter validation study on diastolic  blood pressure thresholds during pediatric CPR and outcomes on behalf of CAPCORN and ICU recess investigators.  I have no personal financial conflicts of interest, but this study does come from the ICU's recess trial that was funded by the NHLBI.  In 1996, Max Harry Wilde, one of the founders of the Society of Critical Care Medicine and Resuscitation Scientists said, performing CPR without measuring the effects is like  flying an airplane without an altimeter. It is well established in animal models that coronary perfusion pressure is the critically  important parameter for successful CPR in these large animal studies and coronary perfusion pressure is the aortic pressure during the relaxation phase minus radiational pressure.  And if the coronary perfusion pressure is greater than 20 or aortic diastolic pressure is greater than 30, the animals will survive and if not, they did not.  Despite these impressive translational animal data, it was generally felt that it was not feasible to measure invasive arterial pressures during CPR, as most of the focus has been  on out-of-hospital cardiac arrests and arrests on wards and hospitals.  Notably, the incidence of pediatric in-hospital CPR in the US is greater than 15,000 per year and 95% of these occur in an intensive care unit.  Perhaps even more importantly, 40 to 50% have arterial catheters and provide the opportunity for us to evaluate the value of blood pressure monitoring.  We took to heart Dr. Weil's challenge that we focus on measuring the blood pressure and looking at outcomes and we looked at personalized hemodynamic-directed CPR and showed that it  improved survival. Personalized CPR was pushing on the chest until we got a systolic pressure of 100 and  giving vasopressors when the coronary perfusion pressure was low and not giving it when it was not low.  As opposed to the more typical rescuer-centric CPR where we pushed the same depth all the time and gave the same dose of epinephrine every four minutes, whether needed or not,  and we showed that in many animal models that outcome was improved, survival outcome was improved with this personalized hemodynamic-directed CPR.  The next step in addressing this issue was to find out what mean diastolic blood pressures during CPR resulted in better outcomes for pediatric cardiac arrest.  We looked at the Pediatric Intensive Care Quality of CPR Study or PICU-CPR and in that we derived the data that showed that when children under a year of age had a mean diastolic  blood pressure greater than 25 millimeters of mercury during CPR and over a year of age had greater than 30 millimeters of mercury, that this resulted in substantial increase  in the likelihood of survival to discharge and to survive with favorable neurologic outcome.  However, these data needed to be validated. The hypothesis of our ICU-resusced diastolic blood pressure validation study is that arterial  diastolic blood pressure during CPR would once again be associated with survival and in particular the exposure we looked at derived from the PICU-CPR study is that if the diastolic  blood pressure was greater than 30 when the child was greater than or equal to one year of age  or was greater than or equal to 25 when less than one year of age, that this would result in  increased survival to hospital discharge, the same primary outcome as in the PICU-CPR study, and would secondarily improve rates of return of spontaneous circulation  and survival with favorable neurologic outcome.  Inclusion criteria included all children under 18 years of age from the prospective ICU-resusced  trial which included 18 PICUs and CICUs in North America from October of 2016 to March of 2020. Each of them had to have greater than or equal to 30 seconds of chest compressions  and had to have invasive blood pressure monitoring that commenced before the arrest and was able to capture the first chest compression and the first 10 minutes of CPR  or until ROSC was attained. Exclusion criteria included an out-of-hospital cardiac arrest that  was related to this ICU admission, inability to determine whether when CPR started and stopped,  inability to determine the diastolic blood pressure for example because of line interruption for blood drops. We gathered at scene-style standardized cardiac arrest and CPR data  including patient factors, arrest factors, characteristics, and outcomes such as return of spontaneous circulation for greater than 20 minutes, survival to discharge, and survival  with favorable neurologic outcome defined as PCPC 1 to 3 or no change. The primary analyses were  multi-variable Poisson regression models with robust error estimates for relationships of mean  diastolic blood pressures greater than 25 and greater than 30 in the infants and children respectively and associated them with outcomes adjusting for age, initial rhythm, illness  category, location, PICU versus CICU, and pre-arrest prison three. We also did exploratory analyses to take a look at other potential diastolic blood pressure thresholds with these  outcomes including mean diastolic blood pressures of 15 and 20 and infants and older children 20  and 25, 30, 35, and 35 and 40. Our a priori power analysis based on preliminary data suggesting an  enrollment of about 1540 patients, 40% with invasive BP monitoring, and a 47% rate of survival  to discharge if they met these diastolic thresholds versus only 31% if they did not, and that 60% would  attain DPB thresholds. Based on all this, we calculated an 85% power to validate the survival  association. In fact, the IC-RSS database had 1129 index CPR events and arterial lines were  present in 49%. 135 of the events were excluded and the CPR events that we analyzed were for 413  patients. These are examples of a few of the pre-arrest and event characteristics which in general were very similar between the PICU CPR derivation group and the ICU resuscitation  validation group such as the number that had that were infants, had post-op cardiovascular surgery,  had shockable rhythms, had causes of arrest or hypotension or respiratory. There was a pretty  substantial difference though that the ICU resuscitation validation cohort had a much higher  number of patients with normal pediatric cerebral performance category prior to the arrest.  In contrast, the CPR hemodynamics were quite different in the two studies.  In the PICU CPR study, only 62% met the thresholds of greater than 25 and greater than 30 in infants  and children versus 86% in the ICU RSS validations database. The mean diastolic blood pressures were  generally higher in the ICU RSS group for both less than a year of age and greater than a year  of age and the mean systolic blood pressure was also higher and that means systolic blood pressure  basically reflects the force of compressions. This slide shows the outcomes in the two studies. As you can see, return of circulation occurred in  about 90% in both studies and in both studies about two-thirds of the patients have returned spontaneous circulation. About a quarter had return of circulation by being put on ECMO.  In contrast, there was a substantial difference in survival to discharge with 59% in the ICU  RSS cohort versus 47% in the PICU CPR and survival with good neurological outcome  with 55% in ICU RSS versus 43% in PICU CPR, presumably from the substantially superior CPR hemodynamics in the ICU RSS cohort. This is the money slide showing the associations  of mean diastolic blood pressures thresholds that were based on the PICU CPR data with outcomes.  As you can see, ROSC was 49% more likely in the patients that met these thresholds. Survival of discharge was 31% more likely and survival with favorable neurologic outcome  appeared to be approximately 29% more likely. However, this did not meet the  threshold of statistical significance. This slide shows our attempted exploratory analyses of alternative DBP thresholds for survival to hospital discharge.  And we looked in five millimeter increments and 10 millimeter increments from the PICU CPR 25 and 30  respective DBP thresholds. Overall, none of the other thresholds had a substantial improvement upon the original PICU CPR data that was derived and that we validated with the  present study. As with all studies, there are limitations. First of all, the observational  design precludes attribution of causality. Second, all of these institutions were large academic,  pediatric, and cardiac intensive care units in the United States. And you can ask the question  about the generalizability of their settings. There was outstanding CPR with excellent hemodynamics  and very impressive outcomes. And only 49% of the patients had invasive arterial blood pressure  monitoring. These thresholds are not useful for the other 51%, but it's precisely these 49%  that we may be able to titrate our CPR for. In conclusion, these ICU-resusced cohort data validate the PICU CPR derivation study, demonstrating that meeting the thresholds  of 25 millimeters of mercury in infants and greater than 30 millimeters of mercury in children  greater than a year of age during CPR is associated with survival to hospital discharge.  The implications are that targeting diastolic blood pressure greater than 25 in infants and greater than 30 in older children during CPR when invasive arterial BP is monitored  may improve outcomes. Future directions clearly focus on the need for an interventional trial of BP-targeted CPR. Thank you.

Video Summary

Bob Berg presented the results of a multicenter validation study on diastolic blood pressure thresholds during pediatric CPR. The study aimed to determine the association between diastolic blood pressure levels during CPR and survival outcomes in pediatric cardiac arrest cases. The study findings validated previous data showing that diastolic blood pressure levels above certain thresholds were associated with improved survival rates and favorable neurological outcomes. The study suggests that targeting specific diastolic blood pressure levels during CPR in pediatric patients may enhance outcomes. Further research is needed to investigate the effectiveness of blood pressure-targeted CPR in improving survival rates.

Asset Subtitle

Resuscitation, Cardiovascular, Pediatrics, 2022

Asset Caption

INTRODUCTION: A prior Collaborative Pediatric Critical Care Network (CPCCRN) derivation study of 164 patients with ICU cardiac arrests (7/2013-6/2016) established that invasive arterial diastolic BP >25mmHg in infants and >30mmHg in children >1yo was associated with survival to hospital discharge with favorable neurologic outcome (aRR 1.6; 1.1-2.5, p=0.02) and survival to discharge (aRR 1.7; 1.2-2.6, p=0.007). We attempted to validate these findings. METHODS: Children ≤18 years old and ≥37 weeks gestation who received chest compressions >1-min duration with invasive BP monitoring before and during CPR (same as derivation set) in 18 ICUs from NHLBI-funded ICU-RESUScitation (NCT028374497) prospective trial (10/2016-3/2020). Standardized CPR data collection included pre-arrest patient characteristics, arterial BPs during first 10 minutes of CPR, intra-arrest interventions and outcomes. Exposure was mean DBP >25mmHg for infants and >30mmHg for older children during the first 10 minutes of CPR. Primary outcome was survival to hospital discharge with favorable neurologic outcome (PCPC 1-3). Multivariable Poisson regression models with robust error estimates evaluated the association of attaining exposure DBP with Return of Spontaneous Circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favorable neurologic outcome RESULTS: Among 1129 ICU-RESUS children with IHCAs, 357 met inclusion criteria. 65% were infants, 8% had initial shockable rhythm, median duration of CPR was 7 [3, 23] minutes, 86% received >1 dose of epinephrine, 85% attained DBP targets >25mmHg in infants or >30mmHg when >1yo. 63% had ROSC, 56% survived to hospital discharge, and 54% survived with favorable neurologic outcome. Adjusting for age, initial rhythm, location (PICU or CICU), and institution, attaining exposure DBP was significantly associated with ROSC (aRR 1.49; 1.13-1.98, P=0.002) and survival to discharge with favorable neurologic outcome (aRR 1.31; 1.00-1.72, P=0.035), but did not reach significance for survival to hospital discharge (aRR 1.29; 0.97-1.70, P=0.056) CONCLUSIONS: These data validate that achieving mean DBP during CPR >25mmHg for infants or >30mmHg for children >1yo is associated with higher rates of successful ROSC and survival to hospital discharge with favorable neurologic outcome.

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Area Cardiovascular

Knowledge Area Pediatrics

Knowledge Level Advanced

Membership Level Select

Tag Cardiopulmonary Resuscitation CPR

Tag Hemodynamic Monitoring

Tag Pediatrics

Tag Cardiothoracic Critical Care

Year 2022

Keywords

Bob Berg

multicenter validation study

diastolic blood pressure thresholds

pediatric CPR

survival outcomes

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