Table 2:
Studies addressing risk factors for mortality after cardiac arrest in pediatric patients with cardiac disease according to setting.
| Author, year | Study design, Setting and period |
Population | Exclusion criteria |
Definition of cardiac arrest |
N patients with CA/N total (%) |
Outcome measures | Predictors/ risk factor for CA associated Mortality | |
|---|---|---|---|---|---|---|---|---|
| Short term mortality No. (%) |
Late mortality No. (%) |
|||||||
| Hospitalized patients | ||||||||
| Gupta P et al., 2016 PCCM | Retrospective analysis of prospective data, GWTG-R (AHA), Multicenter (157 USA Centers) 2000-2010 |
Hospitalized cardiac patients with at least 1 episode of CA | DNR, out-of-hospital CA, newborns in delivery room, NICU patients, CA resolved with implanted defibrillator | Pulseless in-hospital CA requiring chest compressions >1 min | 1889/1889 (100) | No-ROSC**: 563 (29.8) (362 deaths, 201 EPCR) At 24h: 739 (39.1) At discharge: 929 (49.2%) |
NA |
Univariate analysis: Recurrent arrest (p<0.001) Multivariable model: NS |
| Lowry et al., 2013 | Retrospective analysis of prospective data, KID Registry, Multicenter (38 USA States) 2000,2003,2006 |
Hospitalized cardiac patients | Not defined | ICD-9 procedure code |
3709/498610 (0.7) | At discharge 2083 (56.2) | NA |
Multivariable model: RISK: SV OR 1.7 (1.2-2.6). PROTECTIVE: Age<1 yr OR 0.7 (0.6-0.9), cardiac surgery prior to CPR OR 0.6 (0.5-0.8) |
| Gupta et al., 2014 Resuscitation | Retrospective analysis of prospective data, VPS (NACHIRI) Registry, Multicenter (108 USA Centers), 2009-2013 | Hospitalized cardiac patients with at least 1 episode of CA | Patients with “altered code status” | Any event characterized by either pulselessness or critically compromised perfusion treated with external chest compression and/or defibrillation | 2182/ 2182 (100) | At discharge: 34 (95%CI 27-44) per 100 cardiac admissions | NA | Multivariable model: NS |
| Ortmann et al., 2011 | Retrospective analysis of prospective data, GWTG-R (AHA), Multicenter (265 USA Centers), 2000-2008 Overlap data |
Hospitalized cardiac patients with at least 1 episode of CA (medical and surgical) | DNR, out-of-hospital, NICU, newborn in the delivery room, obstetrics patient, shock by an implanted defibrillator | Cessation of cardiac mechanical activity with the absence of palpable central pulse, apnea, and unresponsiveness | 1214/ 1214 (100) | No-ROSC** 632 (52.1) (481 death, 151 ECPR) At 24h 594 (48.9) At discharge 821 (67.6) |
NA |
Multivariable model (Outcome: survival): RISK for cardiac-surgical: renal failure OR 0.1 (CI 0.03, 0.3), heart failure OR 0.5 (CI 0.3, 0.8), beds n<300 OR 0.4 (CI 0.2, 0.9), teaching hospital, OR 0.3 (CI 0.09, 0.8), longer CPR, OR 0.6 (CI 0.5, 0.7). PROTECTIVE for cardiac-surgical: Age 1month-1year OR 2.7 (CI 1.6, 4.4), Age 1year-8year , OR 2.6 (CI 1.4, 4.9), ECPR OR 2.5 (CI 1.3, 4.5). RISK for cardiac medical: CA in the Emergency Department, OR 0.3 (CI 0.1, 0.6), metabolic/electrolyte abnormality OR 0.4 (CI 0.1, 0.96), atropine OR 0.4 (CI 0.2, 0.7), longer CPR duration OR 0.7 (CI 0.6, 0.8). PROTECTIVE for cardiac-medical: arrhythmia OR 2.6 (CI 1.5, 4.3), airways compromise OR 8 (CI 2.5, 26), ECPR OR 3.8 (CI 1.4, 5.8). |
| Ramamoorthy et al., 2010 | Retrospective analysis of prospective data, POCA Registry, Multicenter (79 USA Centers), 1994-2005 |
Hospitalized cardiac patients with at least 1 episode of anesthesia related CA | CAs in the pediatric and neonatal intensive care units or on the ward | Administration of chest compressions or death | 127/ 127 (100) | CA-related death (no time defined): 42 (33.1) ECPR 7/68 – no outcome defined |
NA |
Univariate analysis: Unrepaired lesions compared with palliated or completely repaired lesions (p=0.006), longer total duration of resuscitation (p=0.001), larger number of drugs (p=0.046), and more rounds of drugs (p=0.038) |
| Intensive care unit setting | ||||||||
| Dagan et al., 12 2019 | Retrospective, Single-center (Melbourne, Australia), 2007-2016 | P-CICU patients post cardiac surgery | Children with medical cardiac conditions, children who suffered CA following procedures as cardiac catheterization, CA prior to cardiac surgery, DNR | Cessation of cardiac mechanical activity requiring cardiac massage for ≥1 min | 211/ 4983 (4.3) | At discharge 64 (30.1) | NA |
Univariate analysis: Younger age (p<0.001), male (p=0.001), lower weight (p<0.001), prematurity (p<0.001), chromosomal/genetic syndrome (p<0.001), need for ECMO/VAD (p<0.001), higher RACHS-1 category (p<0.001) |
| Dhillon et al., 17 2018 | Retrospective, Single-center (Texas, USA), 2011-2016 | P-CICU patients who experienced at least 1 CA | Multiple events in the same patient, events with incomplete documentation, CA outside the CICU | CPR ≥ 2 min | 90 (of 150 events over 5,947 unique admissions) (150/5,947=2.5%) |
No-ROSC** 41 (46.0) (18 deaths, 23 ECPR) At 24h 25 (27.8) At discharge 49 (54.4) |
NA |
Univariate analysis: No epinephrine infusion pre-CA (p=0.02 for CHD medical patients, p=0.03 for surgical patients), no arterial line pre-CA (p=0.02 for surgical patients), longer CA duration (p=0.02 for surgical patients), higher number of epinephrine doses (p<0.01 for surgical patients) |
| Yates et al., 16 2019 | Prospective, Multicenter (PICqCPR study, USA centers, CPCCRN network), 2013-2016 |
PICU or P-CICU patients (medical and surgical) with invasive arterial BP monitoring line prior and during CPR | Patients for which first compression was not captured on the waveform data, or compression start and stop could not be determined | CPR for at least 1 min | 113/ 113 (100) | No ROSC** 72 (63.7) (39 deaths, 33 ECPR) At discharge 56 (49.6) |
NA |
Univariate analysis: Diastolic BP ≥25 mmHg for infants or ≥30 mmHg for children (cohort surgical patients only, p=0.018) |
| Gupta et al., 10 2016 Resuscitation | Retrospective analysis of prospective data, VPS (NACHRI) Registry, Multicenter (62 USA Centers) 2009-2014 |
P-CICU patients with CHD post cardiac surgery | ICU readmission, lack of surgical documentation, surgical closure of isolated PDA or surgery not listed in STS-EACTS | Any event characterized by either pulselessness or critically compromised perfusion treated with external chest compression and/or defibrillation | 736/ 26,909 (2.7) | At discharge 229 (31.1) | NA |
Multivariable model: RISK: ECMO OR 3.04 (CI 2.02, 4.57), SV anatomy OR 1.60 (CI 1.04, 2.46), renal failure OR 2.78 (CI 1.70, 4.54), brain hemorrhage OR 3.09 (CI 1.10, 8.62), hemodialysis catheter in place OR 3.42 (CI 1.05, 11.15). PROTECTIVE: younger age (<28days) OR 0.47 (CI 0.28, 0.81), presence of Cardiac PICU OR 0.48 (CI 0.25, 0.92) |
| Gupta et al., 8 2014 Ann Thorac Surg | Retrospective analysis of prospective data, STS-CHSD Registry, Multicenter (97 USA Centers), 2007-2012 |
P-CICU patients with CHD post cardiac surgery | Surgery not classified into one of the STS-EACTS Mortality Categories, missing outcome | Cessation of effective cardiac mechanical function | 1843/ 70,270 (2.6) | At discharge 910 (49.4) | NA |
Multivariable model: Low volume centers (<150 case/y) OR 2.0 (1.52-2.63), low-medium volume centers (150-250 case/y) OR 1.39 (1.09-1.77), STS mortality category 1-3 in low and in medium volume centers (OR 2.29 (1.19-4.41) and 1.88 (1.12-3.18)); STS mortality category 4-5 in low and medium-low volume centers (OR 2.0 (1.37-2.9) and 1.41 (1.03-1.94)). |
| Ahmadi et al., 40 2013* | Single-center (Tehran, Iran), 2001-2002 | P-CICU patients <7 years of age, post cardiac surgery | Not defined | Not defined | 59/529 (11.2) | At discharge 37 (62.7) | NA |
Univariate analysis: Lower mean arterial BP before the CA (p=0.04) |
| Gaies et al., 7 2012 | Retrospective, Single-center (Ann Arbor, USA) 2006-2008 | P-CICU patients with at least 1 episode of CA | Not defined | Event requiring active chest compressions for any duration | 102 (of 2,230 P-CICU admission) (4.6) | No-ROSC ** 27 (16.5) (17 death, 10 ECPR) At discharge 53 (52.0) |
NA |
Multivariable model: Arrest during weekend OR 4.4 (1.2-15.5), experience of primary nurse <1yr OR 9.4 (1.6-55.0), VIS>=20 OR 6.4 (1.8-22.9) |
| Hansen et al., 43 2011 | Case-control, Single-center (Edmonton, Canada) 1996-2005 | NICU patients post cardiac surgery with CPB, ≤6 weeks of age. Cases: at least 1 CPR event, Controls: no CPR events | Cardiac surgery not requiring CPB, patients having CPR preoperatively or in the operating room | Not defined | 29 CA (cases) (of 343 patients post cardiac surgery) (8.5) | No-ROSC ** 17 (8 death, 9 ECPR) (58.6) | At 1 month 11 (37.9) At 2 years 17 (58.6) |
Multivariable model on all cohort,
not on patients with CA only: Minutes of chest compression OR 1.04 (CI 1.01, 1.06) |
| Parra et al., 2 2000 | Retrospective, Single-center (Miami, USA), 1995-1997 | P-CICU patients with at least 1 episode of CA | DNR patients | Cessation of circulation and respiration that required CPR for>2 mins | 32 (38 events) / 32 (100) | No-ROSC** 18 (56.2) (14 deaths, 4 ECPR) At discharge: 18 (56.2) |
At 6 months: 21 (65.6) | Univariate analysis: NS |
| Rhodes et al., 1 1999 | Retrospective, Single-center (New York, USA), 1994-1998 | P-CICU patients with CHD and age <12months post-cardiac surgery | Not defined | Chest compressions or the absence of a palpable spontaneous pulse that was not resolved with only airway intervention | 34/ 575 (5.9) | No-ROSC 11 (32.4) At discharge: 20 (58.8) |
At 6 months 20 (58.8) At follow-up (median 21 months) 21 (61.8) |
Univariate analysis: Lower pre-arrest MAP (p=0.0003), Lower arterial pH (p<0.02), Higher epinephrine doses (p<0.001), Higher bicarbonate dose (p=0.005), Longer CPR duration p<0.001) |
**
for the purpose of this table, ECPR was considered as no return to spontaneous circulation (no-ROSC).
BP: blood pressure; CA: cardiac arrest; CHD: congenital heart disease; CPB: cardiopulmonary bypass; CPR: cardiopulmonary resuscitation; DNR: do not resuscitate; ECPR: ECMO- cardiopulmonary resuscitation; MAP: mean arterial pressure; MV: mechanical ventilation; NA: not applicable; NS: not significant; NICU: neonatal intensive care unit; OR: odds ratio; PAH: pulmonary arterial hypertension; P-CICU: pediatric cardiac intensive care unit; PICU: pediatric intensive care unit; Preop.: preoperative; Postop.: postoperative; RACHS-1: Risk Adjustment for Congenital Heart Surgery-1; ROSC: return of spontaneous circulation; STS: Society of Thoracic Surgeon; SV: single ventricle; VAD: ventricular assist device; VIS: vasopressor inotropic score.