»» Hello. Thank you, guys. I particularly want to thank you because I know you could be having your drink ticket at the PEDS reception right now. So thank you so much for coming. I really do appreciate it. Like Diane said, I'm Charlene Pringle, I'm a nurse practitioner and clinical researcher in the Department of PEDS Critical Care Medicine in Gainesville, Florida at the University of Florida. And my clinical practice is at UF Health Shands Children's Hospital. Today I'm going to be talking to you about a study, sorry, I was just making sure this was working. I didn't realize it was already going to advance. A secondary analysis of a study I recently completed. The overall study is a, I'll give you a little background on it in just a minute. But this particular secondary analysis is talking about the fact that infants are as likely to progress to brain death after out-of-hospital cardiac arrest as children. And this is my study team. And we're presenting on behalf of the Policing Network. I just want to give a special shout out to my three of my co-investigators who are here in the audience. So by way of background, despite recent focuses on post-arrest care, out-of-hospital arrest in children still results in very high mortality. The two main mechanisms of death in children who are admitted to the hospital after out-of-hospital arrest are progression to brain death and withdrawal of life-sustaining therapy for poor prognosis of neurologic recovery. A simple prognostication tool for adults called the Brain Death After Cardiac Arrest Score was recently developed and validated in France. And the citation from CHEST from 2021 is there on the screen. So after reading about that study and thinking about its clinical utility possibly in children, we decided to do a study to apply that score to children and looking at an effort to add a possible objective component to our usual multimodal approach of imaging, serial exams and EEG for prognostication. In this pre-planned secondary study, we looked at comparisons of progression to brain death by age as well as whether duration of arrest could be used to predict outcomes. This was a retrospective cohort study of children admitted to five U.S. PICUs over a 10-year period after out-of-hospital arrest. And we defined out-of-hospital arrest was long enough to require admission to a PICU after your arrest after obtaining ROSC. The score covariates are listed there on the screen as well as a map portraying the participating children's hospitals, which were Shands UF in Gainesville, Florida, Wolfson Children's in Jacksonville, Florida, CHLA, Lurie and University of Maryland. The score elements were extracted for those children who survived at least 24 hours post-arrest which is required for scoring and ultimately died as the result of their arrest. We wanted to compare infants with older children as this sort of common perception that infants may have less progression to brain death after arrest due to their perceived ability to potentially tolerate cerebral edema better due to open fontanels. I've been around for 25 years and I've worked in eight PICUs and everywhere I've worked I've always kind of heard this and I was kind of like, I don't really know that that's true. So let's figure it out. So we defined our cohorts as infants under 12 months and older children which were 12 months to 18 years and we stratified them by outcome. Statistically significant differences were evaluated using t-tests for continuous data and then CHI-square or Cochrane-Mentel-Hensel for categorical data. The prognostic utility of duration of arrest till ROSC and significant risk factors were also evaluated via logistic models within the cohorts. We had 389 children identified, 101 of those died prior to the 24-hour after admission mark required for the scoring. So that left 282 for study inclusion. About 60% of those progressed to formal declaration of brain death which was similar to other recently published works. An additional 20.6% had one formal exam or one documented exam consisted with brain death but had withdrawal of life-sustaining therapy prior to formal declaration. Among those formally declared there was no difference in the rate of prevalence of progression to brain death between age groups. And you can see that it was 74.7% of infants and 75.8% of children. Those results remained consistent when we included those who were likely brain death but had pre-declaration withdrawal which was, you know, another additional part of our population. There was no significant difference in the rate of pre-declaration withdrawal between events of infants and children either, meaning the frequency. So remember this is a secondary analysis of a much bigger study. So here I'm just going to share with you details that are specific to this particular abstract as we've already presented this study elsewhere. So this particular abstract we were talking about, again, the progression within age groups and whether or not duration of arrest till ROSC was predictive. So when adjusted for significantly different risk factors within the age group, prolonged duration of arrest for children was well associated to progression of brain death. And you can see highlighted there the odds ratios for 15 to 30-minute arrest versus greater than 30-minute arrest was almost double. This was not the case for infants which are up here. So recent focus on describing rates and timing of death in pediatric out-of-hospital cardiac arrest has set the stage for development of prognostic tools or guidelines. There's some incredible work going on in this area. What I wanted to kind of contribute was, was there any age-related difference in the rate of progression in these two different age groups? And we, in this 10-year sample from our five U.S. children's hospitals, we did not find a difference between infants and children. And we also did find that prolonged duration of arrest was well associated with progression for children but not for infants. And we intend to kind of use those as foundational elements as we work forward with working towards tools that are infant-specific. Of course there are limitations. Study inclusion was reliant on data extracted from medical records as a retrospective study. So it's possible that this data set was incomplete. This was mitigated by the author's manual review of all deaths in their PICUs over the 10-year timeframe for inclusion when possible. While the sample size was large enough to detect the needed effects in children, it may have been too small for infants. The major limitation of this study was the inclusion of decedents only rather than also including survivors. We did this by design a priori as the potential clinical application for this score is at the critical time point of consideration of early withdrawal of life-sustaining therapy. Finally as a PICU-based study, there was limited capture of patients with underlying cardiac conditions and shockable rhythms. So I will say that four out of the five PICUs that participated were mixed units for part of the data collection time period with units splitting kind of between 2010 and 2020. So we did have some capture of that. But future work could focus on that cohort. With that, I thank you for your attention.

infants

children

cardiac arrest

brain death

prognostic tools