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Published on: January 5, 2018
Cardiac Arrest Outcomes in Children With Preexisting Neurobehavioral Impairment
James R Christensen1,2,3, Beth S Slomine2,4,5, Faye S Silverstein6,7
1Department of Pediatric Rehabilitation Medicine, Kennedy Krieger Institute, Baltimore, MD.
Insights
In children with preexisting neurobehavioral impairment, targeted temperature management trials show one-third survival to 12 months, with varied neurobehavioral outcomes. This highlights challenges in pediatric neuroprotection research.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Clinical trials
Background:
- Children with preexisting neurobehavioral impairment face unique challenges after cardiac arrest.
- Targeted temperature management (TTM) is a critical intervention for post-cardiac arrest care.
- Understanding outcomes in this vulnerable population is crucial for improving neuroprotection strategies.
Purpose of the Study:
- To assess survival and neurobehavioral outcomes at 3 and 12 months in children with preexisting neurobehavioral impairment who underwent TTM.
- To analyze the feasibility and utility of including this population in neuroprotection trials.
Main Methods:
- Secondary analysis of data from two parallel randomized clinical trials (Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital).
- Inclusion of 84 pediatric participants with precardiac arrest neurobehavioral impairment (Vineland Adaptive Behavior Scales, Second Edition composite score < 70).
- Assessment of neurobehavioral function using the Vineland Adaptive Behavior Scales, Second Edition at baseline, 3 months, and 12 months post-cardiac arrest.
Main Results:
- Overall survival to 12 months was 33% (28/84).
- Neurobehavioral scores (Vineland Adaptive Behavior Scales, Second Edition) declined significantly at 3 months post-cardiac arrest.
- At 12 months, neurobehavioral outcomes varied, with 43% (12/28) showing unchanged or improved scores, particularly in the in-hospital cardiac arrest group.
Conclusions:
- Including children with preexisting neurobehavioral impairment in neuroprotection trials is feasible but challenging.
- One-third of these children survived to 12 months, but their neurobehavioral outcomes demonstrated considerable variability.
- Findings underscore the need for tailored approaches and further research in this specific pediatric population.
Objectives:
To describe survival and 3-month and 12-month neurobehavioral outcomes in children with preexisting neurobehavioral impairment enrolled in one of two parallel randomized clinical trials of targeted temperature management.
Design:
Secondary analysis of Therapeutic Hypothermia after Pediatric Cardiac Arrest In-Hospital and Out-of-Hospital trials data.
Setting:
Forty-one PICUs in the United States, Canada, and United Kingdom.
Patients:
Eighty-four participants (59 in-hospital cardiac arrest and 25 out-of-hospital cardiac arrest), 49 males, 35 females, mean age 4.6 years (SD, 5.36 yr), with precardiac arrest neurobehavioral impairment (Vineland Adaptive Behavior Scales, Second Edition composite score < 70). All required chest compressions for greater than or equal to 2 minutes, were comatose and required mechanical ventilation after return of circulation.
Interventions:
Neurobehavioral function was assessed using the Vineland Adaptive Behavior Scales, Second Edition at baseline (reflecting precardiac arrest status), and at 3 and 12 months postcardiac arrest, followed by on-site cognitive evaluation. Vineland Adaptive Behavior Scales, Second Edition norms are 100 (mean) ± 15 (SD); higher scores indicate better function. Analyses evaluated survival, changes in Vineland Adaptive Behavior Scales, Second Edition, and cognitive functioning.
Measurements And Main Results:
Twenty-eight of 84 (33%) survived to 12 months (in-hospital cardiac arrest, 19/59 (32%); out-of-hospital cardiac arrest, 9/25 [36%]). In-hospital cardiac arrest (but not out-of-hospital cardiac arrest) survival rate was significantly lower compared with the Therapeutic Hypothermia after Pediatric Cardiac Arrest group without precardiac arrest neurobehavioral impairment. Twenty-five survived with decrease in Vineland Adaptive Behavior Scales, Second Edition less than or equal to 15 (in-hospital cardiac arrest, 18/59 (31%); out-of-hospital cardiac arrest, 7/25 [28%]). At 3-months postcardiac arrest, mean Vineland Adaptive Behavior Scales, Second Edition scores declined significantly (-5; SD, 14; p < 0.05). At 12 months, Vineland Adaptive Behavior Scales, Second Edition declined after out-of-hospital cardiac arrest (-10; SD, 12; p < 0.05), but not in-hospital cardiac arrest (0; SD, 15); 43% (12/28) had unchanged or improved scores.
Conclusions:
This study demonstrates the feasibility, utility, and challenge of including this population in clinical neuroprotection trials. In children with preexisting neurobehavioral impairment, one-third survived to 12 months and their neurobehavioral outcomes varied broadly.
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