Association of blood pressure with neurologic outcome at hospital discharge after pediatric cardiac arrest resuscitation.

BACKGROUND: Poor outcomes are associated with post cardiac arrest blood pressures <5th percentile for age. We aimed to study the relationship of mean arterial pressure (MAP) with favorable neurologic outcome following cardiac arrest and return of spontaneous circulation (ROSC). 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 hours were included. Lowest documented MAP within the first 6 hours of ROSC was percentile adjusted for age and categorized into six groups - Group I: <5th, II: 5-24th, III: 25-49th, IV: 50-74th, V: 75-94th; and VI: 95-100th percentile. Primary outcome was favorable neurologic status at hospital discharge, defined as PCPC score 1, 2, or no change from pre-arrest baseline. Multivariable logistic regression was performed to analyze the association of MAP group with favorable outcome, controlling for illness category (surgical-cardiac), initial rhythm (shockable), arrest time (weekend or overnight), age, CPR duration, and clustering by site. RESULTS: 787 patients were included: median [Q1,Q3] age 17.9 [4.8,90.6] months; male 58%; OHCA 21%; shockable rhythm 13%; CPR duration 7 [3,16] min; favorable neurologic outcome 54%. Median lowest documented MAP percentile for the favorable outcome group was 13 [3,43] versus 8 [1,37] for the unfavorable group. The distribution of blood pressures by MAP group was I: 37%, II: 28%, III: 13%, IV: 11%, V: 7%, and VI: 4%. Compared with patients in Group I (<5%ile), Groups II, III, and IV had higher odds of favorable outcome (aOR, 1.84 [95% CI, 1.24, 2.73]; 2.20 [95% CI, 1.32, 3.68]; 1.90 [95% CI, 1.12, 3.25]). There was no association between Groups V or VI and favorable outcome (aOR, 1.44 [95% CI, 0.75, 2.80]; 1.11 [95% CI, 0.47, 2.59]). CONCLUSION: In the first 6-hours post-ROSC, a lowest documented MAP between the 5th-74th percentile for age was associated with favorable neurologic outcome compared to MAP <5th percentile for age.

Near-infrared spectroscopy during cardiopulmonary resuscitation for pediatric cardiac arrest: A prospective, observational study.

AIM: Cerebral oxygenation (rSO2) is not routinely measured during pediatric cardiopulmonary resuscitation (CPR). We aimed to determine whether higher intra-arrest rSO2 was associated with return of spontaneous circulation (ROSC) and survival to hospital discharge. METHODS: Prospective, single-center observational study of cerebral oximetry using near-infrared spectroscopy (NIRS) during pediatric cardiac arrest from 2016 to 2020. Eligible patients had ≥30 s of rSO2 data recorded during CPR. We compared median rSO2 and percentage of rSO2 measurements above a priori thresholds for the entire event and the final five minutes of the CPR event between patients with and without ROSC and survival to discharge. RESULTS: Twenty-one patients with 23 CPR events were analyzed. ROSC was achieved in 17/23 (73.9%) events and five/21 (23.8%) patients survived to discharge. The median rSO2 was higher for events with ROSC vs. no ROSC for the overall event (62% [56%, 70%] vs. 45% [35%, 51%], p = 0.025) and for the final 5 minutes of the event (66% [55%, 72%] vs. 43% [35%, 44%], p = 0.01). Patients with ROSC had a higher percentage of measurements above 50% during the final five minutes of CPR (100% [100%, 100%] vs. 0% [0%, 29%], p = 0.01). There was no association between rSO2 and survival to discharge. CONCLUSIONS: Higher cerebral rSO2 during CPR for pediatric cardiac arrest was associated with higher rates of ROSC but not with survival to discharge.

Factors associated with treatment delays in pediatric refractory convulsive status epilepticus.

OBJECTIVE: To identify factors associated with treatment delays in pediatric patients with convulsive refractory status epilepticus (rSE). METHODS: This prospective, observational study was performed from June 2011 to March 2017 on pediatric patients (1 month to 21 years of age) with rSE. We evaluated potential factors associated with increased treatment delays in a Cox proportional hazards model. RESULTS: We studied 219 patients (53% males) with a median (25th-75th percentiles [p25-p75]) age of 3.9 (1.2-9.5) years in whom rSE started out of hospital (141 [64.4%]) or in hospital (78 [35.6%]). The median (p25-p75) time from seizure onset to treatment was 16 (5-45) minutes to first benzodiazepine (BZD), 63 (33-146) minutes to first non-BZD antiepileptic drug (AED), and 170 (107-539) minutes to first continuous infusion. Factors associated with more delays to administration of the first BZD were intermittent rSE (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.14-2.09; p = 0.0467) and out-of-hospital rSE onset (HR 1.5, 95% CI 1.11-2.04; p = 0.0467). Factors associated with more delays to administration of the first non-BZD AED were intermittent rSE (HR 1.78, 95% CI 1.32-2.4; p = 0.001) and out-of-hospital rSE onset (HR 2.25, 95% CI 1.67-3.02; p < 0.0001). None of the studied factors were associated with a delayed administration of continuous infusion. CONCLUSION: Intermittent rSE and out-of-hospital rSE onset are independently associated with longer delays to administration of the first BZD and the first non-BZD AED in pediatric rSE. These factors identify potential targets for intervention to reduce time to treatment.

Nonconvulsive seizures are common in critically ill children.

BACKGROUND: Retrospective studies have reported the occurrence of nonconvulsive seizures in critically ill children. We aimed to prospectively determine the incidence and risk factors of nonconvulsive seizures in critically ill children using predetermined EEG monitoring indications and EEG interpretation terminology. METHODS: Critically ill children (non-neonates) with acute encephalopathy underwent continuous EEG monitoring if they met institutional clinical practice criteria. Study enrollment and data collection were prospective. Logistic regression analysis was utilized to identify risk factors for seizure occurrence. RESULTS: One hundred children were evaluated. Electrographic seizures occurred in 46 and electrographic status epilepticus occurred in 19. Seizures were exclusively nonconvulsive in 32. The only clinical risk factor for seizure occurrence was younger age (p=0.03). Of patients with seizures, only 52% had seizures detected in the first hour of monitoring, while 87% were detected within 24 hours. CONCLUSIONS: Seizures were common in critically ill children with acute encephalopathy. Most were nonconvulsive. Clinical features had little predictive value for seizure occurrence. Further study is needed to confirm these data in independent high-risk populations, to clarify which children are at highest risk for seizures so limited monitoring resources can be allocated optimally, and to determine whether seizure detection and management improves outcome.

Electroencephalographic monitoring during hypothermia after pediatric cardiac arrest.

BACKGROUND: Hypoxic ischemic brain injury secondary to pediatric cardiac arrest (CA) may result in acute symptomatic seizures. A high proportion of seizures may be nonconvulsive, so accurate diagnosis requires continuous EEG monitoring. We aimed to determine the safety and feasibility of long-term EEG monitoring, to describe electroencephalographic background and seizure characteristics, and to identify background features predictive of seizures in children undergoing therapeutic hypothermia (TH) after CA. METHODS: Nineteen children underwent TH after CA. Continuous EEG monitoring was performed during hypothermia (24 hours), rewarming (12-24 hours), and then an additional 24 hours of normothermia. The tolerability of these prolonged studies and the EEG background classification and seizure characteristics were described in a standardized manner. RESULTS: No complications of EEG monitoring were reported or observed. Electrographic seizures occurred in 47% (9/19), and 32% (6/19) developed status epilepticus. Seizures were nonconvulsive in 67% (6/9) and electrographically generalized in 78% (7/9). Seizures commenced during the late hypothermic or rewarming periods (8/9). Factors predictive of electrographic seizures were burst suppression or excessively discontinuous EEG background patterns, interictal epileptiform discharges, or an absence of the expected pharmacologically induced beta activity. Background features evolved over time. Patients with slowing and attenuation tended to improve, whereas those with burst suppression tended to worsen. CONCLUSIONS: EEG monitoring in children undergoing therapeutic hypothermia after cardiac arrest is safe and feasible. Electrographic seizures and status epilepticus are common in this setting but are often not detectable by clinical observation alone. The EEG background often evolves over time, with milder abnormalities improving and more severe abnormalities worsening.