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

Monique M Gardner; David A Hehir; Ron W Reeder; Tageldin Ahmed; Michael J Bell; Robert A Berg; Robert Bishop; Matthew Bochkoris; Candice Burns; Joseph A Carcillo; Todd C Carpenter; J Michael Dean; J Wesley Diddle; Myke Federman; Richard Fernandez; Ericka L Fink; Deborah Franzon; Aisha H Frazier; Stuart H Friess; Kathryn Graham; Mark Hall; Monica L Harding; Christopher M Horvat; Leanna L Huard; Tensing Maa; Arushi Manga; Patrick S McQuillen; Kathleen L Meert; Ryan W Morgan; Peter M Mourani; Vinay M Nadkarni; Maryam Y Naim; Daniel Notterman; Murray M Pollack; Anil Sapru; Carleen Schneiter; Matthew P Sharron; Neeraj Srivastava; Bradley Tilford; Shirley Viteri; David Wessel; Heather A Wolfe; Andrew R Yates; Athena F Zuppa; Robert M Sutton; Alexis A Topjian

doi:10.1186/s13054-023-04662-9

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

Crit Care. 2023 Oct 7;27(1):388. doi: 10.1186/s13054-023-04662-9.

Authors

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.

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.

MeSH terms

Blood Pressure
Cardiopulmonary Resuscitation*
Child
Heart Arrest* / complications
Heart Arrest* / therapy
Hospital Mortality
Humans
Hypotension* / complications
Intensive Care Units

Associated data

ClinicalTrials.gov/NCT02837497

Grants and funding

K23 HL148541/HL/NHLBI NIH HHS/United States