Hemodynamic Patterns Before Inhospital Cardiac Arrest in Critically Ill Children: An Exploratory Study
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Published on: May 26, 2023
Ely Erez1, Mjaye L Mazwi2,3, Alexandra M Marquez2,3
1Faculty of Medicine, Technion, Haifa, Israel.
Insights
Critically ill children show significant drops in cardiac output before cardiac arrest. Three distinct hemodynamic patterns were identified, suggesting potential for earlier detection using arterial blood pressure monitoring.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular physiology
- Clinical data analysis
Background:
- In-hospital cardiac arrest (IHCA) in children is a critical event.
- Understanding pre-arrest physiological changes is crucial for timely intervention.
- Current detection methods may not capture subtle hemodynamic shifts.
Purpose of the Study:
- To characterize the hemodynamic trajectories preceding IHCA in pediatric patients.
- To identify distinct patterns of physiological deterioration before IHCA.
- To explore the potential of arterial blood pressure waveform analysis for early IHCA detection.
Main Methods:
- Retrospective analysis of arterial blood pressure and electrocardiogram waveforms.
- Invasive blood pressure monitoring data from 27 children experiencing 31 IHCA events.
- Assessment of cardiac output, systemic vascular resistance, stroke volume, and heart rate using established estimation methods.
Main Results:
- All patients exhibited substantial pre-arrest declines in cardiac output (65-84% median decrease) within 10 minutes of IHCA.
- Three distinct hemodynamic patterns were identified: subacute pulseless arrest (n=18), acute pulseless arrest (n=7), and bradycardic arrest (n=6).
- Cardiac output decline was mainly due to decreased stroke volume in pulseless arrest groups and decreased heart rate in the bradycardic group.
Conclusions:
- Critically ill children display unique physiological behaviors before IHCA, characterized by significant cardiac output reduction.
- Distinct pre-arrest patterns with varying deterioration rates and contributing factors (heart rate vs. stroke volume) were observed.
- Monitoring arterial blood pressure waveform-derived parameters may enhance early IHCA detection by several minutes.
Abstract:
To characterize prearrest hemodynamic trajectories of children suffering inhospital cardiac arrest.
Design:
Exploratory retrospective analysis of arterial blood pressure and electrocardiogram waveforms.
Setting:
PICU and cardiac critical care unit in a tertiary-care children's hospital.
Patients:
Twenty-seven children with invasive blood pressure monitoring who suffered a total of 31 inhospital cardiac arrest events between June 2017 and June 2019.
Interventions:
None.
Measurements And Main Results:
We assessed changes in cardiac output, systemic vascular resistance, stroke volume, and heart rate derived from arterial blood pressure waveforms using three previously described estimation methods. We observed substantial prearrest drops in cardiac output (population median declines of 65-84% depending on estimation method) in all patients in the 10 minutes preceding inhospital cardiac arrest. Most patients' mean arterial blood pressure also decreased, but this was not universal. We identified three hemodynamic patterns preceding inhospital cardiac arrest: subacute pulseless arrest (n = 18), acute pulseless arrest (n = 7), and bradycardic arrest (n = 6). Acute pulseless arrest events decompensated within seconds, whereas bradycardic and subacute pulseless arrest events deteriorated over several minutes. In the subacute and acute pulseless arrest groups, decreases in cardiac output were primarily due to declines in stroke volume, whereas in the bradycardic group, the decreases were primarily due to declines in heart rate.
Conclusions:
Critically ill children exhibit distinct physiologic behaviors prior to inhospital cardiac arrest. All events showed substantial declines in cardiac output shortly before inhospital cardiac arrest. We describe three distinct prearrest patterns with varying rates of decline and varying contributions of heart rate and stroke volume changes to the fall in cardiac output. Our findings suggest that monitoring changes in arterial blood pressure waveform-derived heart rate, pulse pressure, cardiac output, and systemic vascular resistance estimates could improve early detection of inhospital cardiac arrest by up to several minutes. Further study is necessary to verify the patterns witnessed in our cohort as a step toward patient rather than provider-centered definitions of inhospital cardiac arrest.
