Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest

Abstract

IMPORTANCE-Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described during targeted temperature management.OBJECTIVE-To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. DESIGN, SETTING, AND PARTICIPANTS-This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1, 2009, through December 31, 2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5, 2016, through June 13, 2017. EXPOSURES-Hypotension. MAIN OUTCOMES AND MEASURE-Survival to hospital discharge. RESULTS-Of 292 children (194 boys [66.4%] and 98 girls [33.6%]; median age, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) or rewarming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74).CONCLUSIONS AND RELEVANCE-In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10%. 1,2 After initial resuscitation from OHCA and admission to a pediatric intensive care unit, many children die ...

Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes

“…First, there may be concern that our findings are not generalizable because all patients had an arterial line in place at the time of arrest; however, more than 95% of pediatric in-hospital cardiac arrests now occur in ICUs, and over half will have an arterial line in place at the time of the arrest (37). Second, other important CPR quality variables (compression depth (11), release velocity (9), ventilation rate (38)) and quality of postarrest care (39, 40) are not evaluated. While inclusion of CCF did not substantially affect our results (data not shown), the contribution of depth to this association remains unknown highlighting the need for further research in this area.…”

Risks According to the Timing and Frequency of Hypotension Episodes in Postanoxic Comatose Patients

“…It is understandable that repeated hypotension is associated with poorer neurological outcome, but it is notable that hypotension episodes within 6 h or 12 h after TTM initiation were found to be comparatively more hazardous. In a previous study on hypotension episodes found within 6 h and 72 h after TTM initiation in pediatric patients with cardiac arrest, it was shown that patients with hypotension episodes in the early phase after TTM initiation (within 6 h after TTM initiation) had a poorer neurological outcome than those with hypotension episodes within 72 h after TTM initiation [ 18 ]. Consistent results were shown in the present study, which included adult patients (within 6 h vs. within 4 days after TTM initiation: HR 1.693 vs. 1.51).…”

“…The fact that hypotension episodes in the early phase after TTM initiation are most dangerous can be attributed to the fact that the brain or heart are especially vulnerable to hypotension in the early phase after TTM initiation [ 18 ] or to the fact that TTM performed within 24 h after ROSC decreases brain blood flow, such as the mean flow velocity in the middle cerebral artery, resulting in more damage to the brain [ 23 , 24 ]. Moreover, cerebral autoregulation can be reduced or right shifted after OHCA [ 25 ].…”

“…The exclusion criteria were as follows: patients who had rearrest events or death within 24 h on admission, acute hemorrhagic or ischemic stroke (according to a local protocol for stroke patients, they were treated with prolonged TTM for about 7 days), limitations in therapy or a do not resuscitate (DNR) order, a prearrest cerebral performance category (CPC) score of 3 or 4, chronic diseases yielding little probability of survival over 180 days, a body temperature of <30 °C on admission; and patients whose caregiver did not sign the written informed consent form were excluded from the study ( Figure 1 ). The patients were divided into the no-hypotension and hypotension groups before TTM initiation and in the early and late phase after TTM initiation on the basis of the hypotension episodes’ timing at admission or in the early and late phase that were previously studied ( Figure 1 ) [ 10 , 18 ]. Additionally, the no-hypotension and hypotension groups were compared to identify the relation with unfavorable neurological outcome and complications before TTM initiation and during the TTM period.…”

Therapeutic hypothermia after paediatric cardiac arrest: Pooled randomized controlled trials

“…This suggests hypothermia may have been protective or provided additional inotropic effects for the myocardium in the early post arrest period. Early hypotension in the first 6 to 12 hours post cardiac arrest is associated with worse outcome in children comatose after cardiac arrest(21,22). Hypothermia has been reported to reduce inotropic or vasopressor requirement and reduce/rebalance myocardial work to oxygen demand(23).…”