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

Monique M. Gardner, 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.
David A. Hehir, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Ron W. Reeder, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Tageldin Ahmed, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
Michael J. Bell, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
Robert A. Berg, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Robert Bishop, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
Matthew Bochkoris, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
Candice Burns, Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA.
Joseph A. Carcillo, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
Todd C. Carpenter, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
J Michael Dean, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
J Wesley Diddle, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Myke Federman, Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA.
Richard Fernandez, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
Ericka L. Fink, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
Deborah Franzon, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
Aisha H. Frazier, Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA.
Stuart H. Friess, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
Kathryn Graham, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Mark Hall, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
Monica L. Harding, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Christopher M. Horvat, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
Leanna L. Huard, Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA.
Tensing Maa, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA.
Arushi Manga, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
Patrick S. McQuillen, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA.
Kathleen L. Meert, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA.
Ryan W. Morgan, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Peter M. Mourani, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA.
Vinay M. Nadkarni, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
Maryam Y. Naim, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.

Document Type

Journal Article

Publication Date

10-7-2023

Journal

Critical care (London, England)

Volume

27

Issue

1

DOI

10.1186/s13054-023-04662-9

Keywords

Blood pressure; Cardiopulmonary resuscitation; Hypotension; Infant; Neonatal; Outcomes; Pediatric; Post-cardiac arrest

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.

Department

Pediatrics

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