Prevalence and Outcomes of Pediatric In-Hospital Cardiac Arrest Associated With Pulmonary Hypertension

Morgan RW, Topjian AA, Wang Y, Atkin NJ, Kilbaugh TJ, McGowan FX, Berg RA, Mercer-Rosa L, Sutton RM, Himebauch AS.
Pediatr Crit Care Med. 2020 Apr;21(4):305-313. doi: 10.1097/PCC.0000000000002187.
PMID: 31688674
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Objectives: In adult in-hospital cardiac arrest, pulmonary hypertension is associated with worse outcomes, but pulmonary hypertension-associated in-hospital cardiac arrest has not been well studied in children. The objective of this study was to determine the prevalence of pulmonary hypertension among children with in-hospital cardiac arrest and its impact on outcomes.

Design: Retrospective single-center cohort study.

Setting: PICU of a quaternary care, academic children’s hospital.

Patients: Children (<18 yr old) receiving greater than or equal to 1 minute of cardiopulmonary resuscitation (cardiopulmonary resuscitation) for an index in-hospital cardiac arrest with an echocardiogram in the 48 hours preceding in-hospital cardiac arrest, excluding those with cyanotic congenital heart disease.

Interventions: None.

Measurements and main results: Of 284 in-hospital cardiac arrest subjects, 57 (20%) had evaluable echocardiograms, which were analyzed by a cardiologist blinded to patient characteristics. Pulmonary hypertension was present in 20 of 57 (35%); nine of 20 (45%) had no prior pulmonary hypertension history. Children with pulmonary hypertension had worse right ventricular systolic function, measured by fractional area change (p = 0.005) and right ventricular global longitudinal strain (p = 0.046); more right ventricular dilation (p = 0.010); and better left ventricular systolic function (p = 0.001). Children with pulmonary hypertension were more likely to have abnormal baseline functional status and a history of chronic lung disease or acyanotic congenital heart disease and less likely to have sepsis or acute kidney injury. Children with pulmonary hypertension were more likely to have an initial rhythm of pulseless electrical activity or asystole and were more frequently treated with inhaled nitric oxide (80% vs 32%; p < 0.001) at the time of cardiopulmonary resuscitation. On multivariable analysis, pulmonary hypertension was not associated with event survival (14/20 [70%] vs 24/37 [65%]; adjusted odds ratio, 1.30 [CI95, 0.25-6.69]; p = 0.77) or survival to discharge (8/20 [40%] vs 10/37 [27%]; adjusted odds ratio, 1.17 [CI95, 0.22-6.44]; p = 0.85).

Conclusions: Pulmonary hypertension physiology preceding pediatric in-hospital cardiac arrest may be more common than previously described. Among this cohort with a high frequency of inhaled nitric oxide treatment during cardiopulmonary resuscitation, pulmonary hypertension was not associated with survival outcomes.

Conflict of interest statement

Copyright form disclosure: Dr. Morgan disclosed that this work was internally funded by the Department of Anesthesiology and Critical Care Medicine at the Children’s Hospital of Philadelphia. His institution received funding from National Institutes of Health (NIH) National Institute of Child Health and Human Development (NICHD) and the NIH National Heart, Lung, and Blood Institute (NHLBI) and he is a member of the American Heart Association (AHA) Emergency Cardiovascular Care Committee. Dr. Kilbaugh’s institution received funding from the Department of Defense, NHLBI, National Institute of Neurological Disorders and Stroke, and Mallinckrodt Pharmaceuticals. Dr. McGowan’s institution received funding from Merck and Transonic Systems and he received funding from Merck. Dr. Berg’s institution received support from the NICHD and NHLBI; Dr. Sutton’s institution received funding from the NICHD, NHLBI, and Mallinckrodt Pharmaceuticals; he received funding from Zoll Medical (speaking honoraria); he was a member of the 2015 and 2018 AHA Pediatric Advanced Life Support writing group, is the Chair of the AHA’s Get with the Guidelines-Resuscitation Registry Pediatric Research Task Force and he disclosed he is a member of the following subcommittees of the AHA Emergency Cardiovascular Care Committee: Systems of Care, Pediatric Emphasis Group, and Science Review Committee. Dr. Himebauch received funding from the Society of Critical Care Medicine (payment and travel expenses for teaching pediatric bedside ultrasound courses). The remaining authors have disclosed that they do not have any potential conflicts of interest.