Evaluating post-cardiac arrest blood pressure thresholds associated with neurologic outcome in children: Insights from the pediRES-Q database

A Ushpol; S Je; A Christoff; G Nuthall; B Scholefield; R W Morgan; V Nadkarni; S Gangadharan; pediRES-Q investigators

doi:10.1016/j.resuscitation.2024.110468

Evaluating post-cardiac arrest blood pressure thresholds associated with neurologic outcome in children: Insights from the pediRES-Q database

Resuscitation. 2024 Dec 18:110468. doi: 10.1016/j.resuscitation.2024.110468. Online ahead of print.

Authors

A Ushpol¹, S Je², A Christoff³, G Nuthall⁴, B Scholefield⁵, R W Morgan², V Nadkarni², S Gangadharan⁶; pediRES-Q investigators

Collaborators

pediRES-Q investigators:
Kamal Abulebda⁷, Diane Atkins⁸, Shilpa Balikai⁸, Marc Berg⁹, Robert Berg¹⁰, Matthew S Braga¹¹, Corinne Buysse¹², Adam Cheng¹³, Andrea Christoff¹⁴, Kelly Corbett¹¹, Allan DeCaen¹⁵, Destiny LaShoto¹⁶, Gabry deJong¹², Jimena Del Castillo¹⁷, Maya Dewan¹⁸, Aaron Donoghue¹⁰, Ivie Esangbedo¹⁹, Stuart Friess²⁰, Sandeep Gangadharan²¹, Orsola Gawronski²², Jonathan Gilleland¹³, Heather Griffis²³, James Gray¹⁸, Helen Harvey²⁴, Ilana Harwayne-Gidansky²⁵, Sarah Haskell⁸, Jennifer Hayes²⁶, Kiran Heber¹⁶, Betsy Hunt²⁷, Takanari Ikeyama²⁸, Priti Jani²⁹, Monica Kleinman³⁰, Lynda Knight³¹, Hiroshi Kurosawa³², Kasper Glerup Lauridsen³³, Tara Lemoine³⁴, Tensing Maa³⁵, Elizabeth Masse³⁶, Luz Marina Mejia³⁷, Yee Hui Mok³⁸, Ryan Morgan¹⁰, Vinay Nadkarni¹⁰, Sholeen Nett¹¹, Abhay Ranganathan¹⁰, Amanda O'Halloran¹⁰, Michelle Olson³⁹, Gene Ong³⁸, Andrea Maxwell⁴⁰, Tia Raymond⁴¹, Joan Roberts³⁶, Anita Sen⁴², Sophie Skellet⁴³, Daniel Stromberg⁴⁴, Felice Su³¹, Robert Sutton¹⁰, Todd Sweberg⁴⁵, Oscar Tegg¹⁴, Ken Tegtmeyer⁴⁶, Alexis Topjian¹⁰, Claire Hanson⁴⁷, Javier Urbano Villaescusa¹⁷, Ichiro Watanabe⁴⁸, Denise Welsby⁴³, Jesse Wenger³⁶, Heather Wolfe¹⁰, Andrea Yeo⁴⁹, Pricilla Yu⁵⁰, Rhea Vidrine⁵¹, Gim Tan⁵², Afsaneh Pirzadeh⁵³, Angela Wratney⁵⁴, Kimberly DiMaria⁵⁵

Affiliations

¹ Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, USA. Electronic address: [email protected].
² Departments of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
³ Pediatric Intensive Care Unit, The Children's Hospital at Westmead, Corner Hawkesbury Road and, Hainsworth St, Sydney, NSW 2145, Australia.
⁴ Department of Pediatric Critical Care, Starship Children's Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand.
⁵ University of Toronto, The Hospital for Sick Children, 555 University Ave, Toronto, ON MG5 1X8, Canada.
⁶ Department of Pediatrics, Division of Critical Care Medicine, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, 1184 5th Ave, New York, NY 10029, USA.
⁷ Riley Hospital for Children, Indianapolis, IN, USA.
⁸ University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
⁹ Lucile Packard Children's Hospital, Palo Alto, CA, USA.
¹⁰ The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
¹¹ Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
¹² Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
¹³ Alberta Children's Hospital, Calgary, AB, Canada.
¹⁴ Children's Hospital at Westmead, Sydney, NSW, Australia.
¹⁵ Stollery Children's Hospital, Edmonton, AB, Canada.
¹⁶ Children's Healthcare of Atlanta, Atlanta, GA, USA.
¹⁷ Hospital Maternoinfantil Gregorio Marañón, Madrid, Spain.
¹⁸ Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
¹⁹ Seattle Children's Medical Center, Seattle, WA, USA.
²⁰ St. Louis Children's Hospital, St. Louis, MO, USA.
²¹ Mount Sinai Kravis Children's Hospital, New York, NY, USA.
²² Ospedale Pediatrico Bambino Gesù, Rome, Italy.
²³ Healthcare Analytics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
²⁴ Rady Children's Hospital, San Diego, CA, USA.
²⁵ Albany Medica Center, Albany, NY, USA.
²⁶ Children's Hospital of Orange County, Los Angeles, CA, USA.
²⁷ Johns Hopkins University School of Medicine, Baltimore, MD, USA.
²⁸ Aichi Children's Health and Medical Center, Obu, Aichi, Japan.
²⁹ The University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA.
³⁰ Boston Children's Hospital, Boston, MA, USA.
³¹ Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
³² Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan.
³³ The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Aarhus University Hospital, Aarhus, Denmark.
³⁴ Valley Children's Hospital, Madera, CA, USA.
³⁵ Nationwide Children's Hospital, Columbus, OH, USA.
³⁶ Seattle Children's Hospital, Seattle, WA, USA.
³⁷ Instituto de Ortopedia Infantil Roosevelt, Bogota, Colombia.
³⁸ KK Women's & Children's Hospital, Singapore.
³⁹ Children's Hospital of Richmond, Richmond, VA, USA.
⁴⁰ Children's Hospital of Wisconsin, Milwaukee, WI, USA.
⁴¹ Medical City Children's Hospital, Dallas, TX, USA.
⁴² NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA.
⁴³ Great Ormond Street Hospital, London, UK.
⁴⁴ Dell Children's Medical Center, Austin, TX, USA.
⁴⁵ Cohen Children's Medical Center, New Hyde Park, NY, USA.
⁴⁶ Cincinnati Children's Hospital, Cincinnati, OH, USA.
⁴⁷ Akron Children's Hospital, Akron, OH, USA.
⁴⁸ Tokyo Metropolitan Children's Hospital, Fuchū, Tokyo, Japan.
⁴⁹ National University Children's Medical Institute, Singapore.
⁵⁰ UT Southwestern Dallas Children's Medical Center, Dallas, TX, USA.
⁵¹ University of Kentucky College of Medicine, Lexington, KY, USA.
⁵² Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA.
⁵³ North Carolina Children's Hospital, Chapel Hill, NC, USA.
⁵⁴ Upstate Golisano Children's Hospital, Syracuse, NY, USA.
⁵⁵ Colorado Children's Hospital, Aurora, CO, USA.

PMID: 39706470
DOI: 10.1016/j.resuscitation.2024.110468

Abstract

Background: Current Pediatric Advanced Life Support Guidelines recommend maintaining blood pressure (BP) above the 5th percentile for age following return of spontaneous circulation (ROSC) after cardiac arrest (CA). Emerging evidence suggests that targeting higher thresholds, such as the 10th or 25th percentiles, may improve neurologic outcomes. We aimed to evaluate the association between post-ROSC BP thresholds and neurologic outcome, hypothesizing that maintaining mean arterial pressure (MAP) and systolic blood pressure (SBP) above these thresholds would be associated with improved outcomes at hospital discharge.

Methods: This retrospective, multi-center, observational study analyzed data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q). Children (<18 years) who achieved ROSC following index in-hospital or out-of-hospital cardiac arrest and survived ≥ 6 h were included. Multivariable logistic regression was preformed to analyze the association between the pre-defined BP thresholds (5th, 10th, and 25th percentiles) and favorable neurologic outcome, controlling for illness category (surgical-cardiac), initial rhythm (shockable), arrest time (weekend or night), age, CPR duration, and clustering by site.

Results: There were 787 patients with evaluable MAP data and 711 patients with evaluable SBP data. Fifty-four percent (N = 424) of subjects with MAP data and 53 % (N = 380) with SBP data survived to hospital discharge with favorable neurologic outcome. MAP above the 5th, 10th, and 25th percentile thresholds was associated with significantly greater odds of favorable outcome compared to patients with MAP below target (aOR, 1.81 [95 % CI, 1.32, 2.50]; 1.50 [95 % CI, 1.10, 2.05]; 1.40 [95 % CI, 1.01, 1.94], respectively). Subjects with lowest SBP above the 5th percentile also had greater odds of favorable outcome (aOR, 1.44 [95 % CI, 1.04, 2.01]). Associations between lowest SBP above the 10th percentile and 25th percentile did not reach statistical significance (aOR 1.33 [95 % CI, 0.96, 1.86]; 1.23 [95 % CI, 0.87, 1.75], respectively).

Conclusion: After pediatric CA, maintaining MAP above the 5th, 10th, and 25th percentiles and SBP above the 5th percentile during the first 6 h following ROSC was significantly associated with improved neurologic outcomes.

Keywords: Blood pressure; Cardiopulmonary resuscitation; Hypotension; Outcomes; Pediatrics; Post-cardiac arrest.