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Timing and Cause of Death in Children Following Return of Circulation After Out-of-Hospital Cardiac Arrest: A
Maayke Hunfeld1,2, Vinay M Nadkarni3, Alexis Topjian3
1Department of Pediatric Neurology, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands.
Insights
More than half of children who survived out-of-hospital cardiac arrest died in the pediatric intensive care unit (PICU). Most deaths resulted from withdrawing life-sustaining therapies due to poor neurologic prognosis, often occurring early after return of circulation.
Area of Science:
- Pediatric critical care medicine
- Pediatric cardiology
- Neurology
Background:
- Out-of-hospital cardiac arrest (OHCA) in children is a critical event requiring intensive care.
- Understanding the causes and timing of death after return of circulation (ROC) is crucial for improving outcomes.
Purpose of the Study:
- To determine the timing and causes of death in children admitted to the pediatric intensive care unit (PICU) following ROC after OHCA.
- To analyze factors associated with survival and identify patterns in mortality.
Main Methods:
- Retrospective observational cohort study at a single tertiary-care hospital PICU.
- Included children under 18 with OHCA and ROC between 2012 and 2017.
- Analyzed general, resuscitation, and post-ROC characteristics, classifying modes of death.
Main Results:
- 44% of 113 children survived to hospital discharge; 56% did not.
- Leading cause of death was withdrawal of life-sustaining therapies due to poor neurologic prognosis (67% of non-survivors).
- Survivors had witnessed arrest, initial shockable rhythm, shorter CPR duration, and better early neurologic exams.
Conclusions:
- Over half of children achieving ROC after OHCA died in the PICU.
- Withdrawal of therapies based on poor neurologic prognosis was common and occurred early.
- There is a need for international guidelines for accurate neuroprognostication in pediatric cardiac arrest survivors.
Objectives:
To determine timing and cause of death in children admitted to the PICU following return of circulation after out-of-hospital cardiac arrest.
Design:
Retrospective observational study.
Setting:
Single-center observational cohort study at the PICU of a tertiary-care hospital (Erasmus MC-Sophia, Rotterdam, The Netherlands) between 2012 and 2017.
Patients:
Children younger than 18 years old with out-of-hospital cardiac arrest and return of circulation admitted to the PICU.
Measurements And Results:
Data included general, cardiopulmonary resuscitation and postreturn of circulation characteristics. The primary outcome was defined as survival to hospital discharge. Modes of death were classified as brain death, withdrawal of life-sustaining therapies due to poor neurologic prognosis, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure, and recurrent cardiac arrest without return of circulation. One hundred thirteen children with out-of-hospital cardiac arrest were admitted to the PICU following return of circulation (median age 53 months, 64% male, most common cause of out-of-hospital cardiac arrest drowning [21%]). In these 113 children, there was 44% survival to hospital discharge and 56% nonsurvival to hospital discharge (brain death 29%, withdrawal of life-sustaining therapies due to poor neurologic prognosis 67%, withdrawal of life-sustaining therapies due to refractory circulatory and/or respiratory failure 2%, and recurrent cardiac arrest 2%). Compared with nonsurvivors, more survivors had witnessed arrest (p = 0.007), initial shockable rhythm (p < 0.001), shorter cardiopulmonary resuscitation duration (p < 0.001), and more favorable clinical neurologic examination within 24 hours after admission. Basic cardiopulmonary resuscitation event and postreturn of circulation (except for the number of extracorporeal membrane oxygenation) characteristics did not significantly differ between the withdrawal of life-sustaining therapies due to poor neurologic prognosis and brain death patients. Timing of decision-making to withdrawal of life-sustaining therapies due to poor neurologic prognosis ranged from 0 to 18 days (median: 0 d; interquartile range, 0-3) after cardiopulmonary resuscitation. The decision to withdrawal of life-sustaining therapies was based on neurologic examination (100%), electroencephalography (44%), and/or brain imaging (35%).
Conclusions:
More than half of children who achieve return of circulation after out-of-hospital cardiac arrest died after PICU admission. Of these deaths, two thirds (67%) underwent withdrawal of life-sustaining therapies based on an expected poor neurologic prognosis and did so early after return of circulation. There is a need for international guidelines for accurate neuroprognostication in children after cardiac arrest.
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