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Outcomes, Characteristics, and Physiology of In-Hospital Cardiac Arrest in Children With Sepsis
Ryan W Morgan1, Ron W Reeder2, Joseph A Carcillo3
1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA.
Insights
Children with sepsis before in-hospital cardiac arrest (IHCA) had significantly lower survival rates and worse neurological outcomes. Sepsis also increased illness severity before and after IHCA, impacting recovery.
Area of Science:
- Pediatric Critical Care Medicine
- In-Hospital Cardiac Arrest Research
- Sepsis Outcomes
Background:
- Prearrest sepsis is linked to poor outcomes in pediatric in-hospital cardiac arrest (IHCA).
- Limited research exists on sepsis's specific impact on IHCA in children.
Purpose of the Study:
- To investigate the association between prearrest sepsis and IHCA outcomes in pediatric intensive care unit (ICU) patients.
- To examine the relationship between sepsis and intra-arrest physiology during cardiopulmonary resuscitation (CPR).
Main Methods:
- Secondary analysis of the ICU Resuscitation Project clinical trial.
- Included children (≤18 years) experiencing an index IHCA across 18 pediatric ICUs in the US.
- Compared outcomes between patients with and without prearrest sepsis using multivariable regression.
Main Results:
- 16.3% of 1129 children with IHCA had prearrest sepsis.
- Sepsis patients had higher comorbidity, illness severity, and vasoactive-inotropic scores.
- Survival to discharge with favorable neurologic outcome was lower in sepsis patients (28.3% vs 58.4%).
- Intra-arrest diastolic blood pressure did not differ, but sepsis survivors required more vasoactives and had higher mortality post-arrest.
Conclusions:
- Prearrest sepsis is associated with significantly worse survival and neurologic outcomes following pediatric IHCA.
- Intra-arrest physiology (diastolic blood pressure) was similar, but post-arrest severity and mortality were higher in sepsis patients.
- Sepsis complicates pediatric IHCA, necessitating further research into targeted interventions.
Objectives:
Prearrest sepsis has been associated with particularly poor outcomes among children who suffer in-hospital cardiac arrest (IHCA), but there is a paucity of dedicated studies on the topic. In this study of children receiving cardiopulmonary resuscitation (CPR) in the ICU, our objective was to determine the associations of sepsis with IHCA outcomes and intraarrest physiology.
Design:
Prospectively designed secondary analysis of the ICU Resuscitation Project clinical trial (NCT02837497).
Setting:
The 18 pediatric and pediatric cardiac ICUs at ten children's hospitals in the United States.
Patients:
Children (≤ 18 yr) with an index IHCA event.
Interventions:
None.
Measurements And Main Results:
The primary exposure was a prearrest diagnosis of sepsis. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was average diastolic blood pressure (DBP) during CPR. Multivariable regression models controlling for a priori covariates assessed the relationship between sepsis and outcomes. Of 1129 children with index IHCAs, 184 (16.3%) had prearrest sepsis. Patients with sepsis had greater prearrest comorbidities, higher prearrest severity of illness, and higher Vasoactive-Inotropic Scores than patients without sepsis. They more frequently had hypotension as the cause of IHCA, had longer durations of CPR, and more frequently received epinephrine and sodium bicarbonate during CPR. They less frequently achieved survival with favorable neurologic outcome (52/184 [28.3%] vs. 552/945 [58.4%]; p < 0.001; adjusted relative risk, 0.54; 95% CI, 0.43-0.68; p < 0.001). Intraarrest DBPs did not differ between patients with vs. without sepsis. Following IHCA, event survivors with sepsis had higher vasoactive requirements, more frequently experienced hypotension, and continued to have greater mortality rates through 48 hours postarrest.
Conclusions:
Children with prearrest sepsis had worse survival outcomes, similar intraarrest DBPs, and greater pre and postarrest severity of illness than children without sepsis.
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