Epidemiology and Outcomes of Cardiac Arrest in Pediatric Cardiac ICUs*

Abstract

Objectives In-hospital cardiac arrest (CA) occurs in 2.6%–6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about CA in pediatric cardiac intensive care units (CICU), therefore we aimed to describe CA epidemiology in a contemporary multicenter CICU cohort. Design Retrospective analysis within the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry. Setting CICUs within 23 North American hospitals Patients All cardiac medical and surgical patients admitted from 8/2014–7/2016 Interventions None Measurements and Main Results There were 15,908 CICU encounters (6498 medical, 9410 surgical). 3.1% had CA; rate was 4.8 CA/1000 CICU days. Medical encounters had 50% higher rate of CA compared to surgical encounters. Observed (unadjusted) CICU CA prevalence varied from 1–5.5% among the 23 centers; CA/1000 CICU days varied from 1.1 to 10.4. Over half CA occur within 48hrs of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and STS-European Association for Cardiothoracic Surgery mortality category 4,5 had strongest association with surgical encounter CA. In medical encounters independent CA risk factors were acute heart failure, prematurity, lactic acidosis >3mmol/dL, and invasive ventilation 1hr after admission. Median cardiopulmonary resuscitation (CPR) duration was ten minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal CPR in 27.2%. Unadjusted survival was 53.2% in encounters with CA vs. 98.2% without. Medical encounters had lower survival after CA (37.7%) vs. surgical encounters (62.5%); Norwood patients had less than half the survival after CA (35.6%) compared to all others. Unadjusted survival after CA varied greatly among 23 centers. Conclusions We provide contemporary epidemiologic and outcome data for CA occurring in the CICU from a multicenter clinical registry. As detailed above, we highlight high-risk patient cohorts and periods of time that may serve as targets for research and QI initiatives aimed at CA prevention.

Current monitoring and innovative predictive modeling to improve care in the pediatric cardiac intensive care unit

“…The rate of CA following pediatric cardiac surgery is variable among centers, but has been reported to occur in 2.6-6% of patient encounters, and is associated with significantly higher mortality regardless of complexity of surgery (6,(25)(26)(27). Neonates, premature infants, and those undergoing the highest complexity surgeries, in particular stage I palliation for single ventricle lesions, represent some of the highest risk post-operative cohorts in the PCICU for CA (6). Patients with medical cardiac disease, such as acquired cardiomyopathies and myocarditis, also have a significant risk of CA and have worse survival compared to post-operative patients (5,6,28).…”

“…Increased pulmonary blood flow occurs at the expense of systemic blood flow, and compensatory circulatory mechanisms that increase systemic vascular resistance further reduce systemic oxygen delivery (1). Patients with this physiology are at high risk for clinical decompensation, cardiac arrest (CA), and mortality (5,6). Their unique physiology makes recognition of decompensation difficult to recognize with current monitoring modalities.…”

“…Although these events are rare they consume a large proportion of medical costs, therapies, and morbidity (6,(23)(24)(25). The rate of CA following pediatric cardiac surgery is variable among centers, but has been reported to occur in 2.6-6% of patient encounters, and is associated with significantly higher mortality regardless of complexity of surgery (6,(25)(26)(27). Neonates, premature infants, and those undergoing the highest complexity surgeries, in particular stage I palliation for single ventricle lesions, represent some of the highest risk post-operative cohorts in the PCICU for CA (6).…”

“…Neonates, premature infants, and those undergoing the highest complexity surgeries, in particular stage I palliation for single ventricle lesions, represent some of the highest risk post-operative cohorts in the PCICU for CA (6). Patients with medical cardiac disease, such as acquired cardiomyopathies and myocarditis, also have a significant risk of CA and have worse survival compared to post-operative patients (5,6,28). The extent to which CA is preventable is unclear, but studies have identified that physiologic features and signs are present prior to clinical decompensation, although sometimes either not identified or inadequately communicated between nurses and physicians (29).…”

Development of a Congenital Heart Surgery Composite Quality Metric: Part 1—Conceptual Framework

“…However, the definition has been revised over time to align more with accepted definitions used across other registries, and a review by the investigative panel of cardiac arrest rates in the STS-CHSD compared with other registries collecting detailed information on cardiac arrest showed similar event rates (data not shown). In addition, there are ongoing efforts in the field specifically geared toward reducing cardiac arrest and variation across centers, including those led by the American Heart Association and the Pediatric Cardiac Critical Care Consortium, emphasizing the importance of this complication [26, 27]. Finally, the panel reviewed prior work demonstrating the impact of cardiac arrest on outcomes as well as resource use [19, 26, 27].…”