Pediatric survival of in-hospital cardiac arrest improving, but remains low

A study of in-hospital cardiac arrest survival rates in children found that hospitals participating in the Get With the Guidelines-Resuscitation (GWTG-Resuscitation) program have improved overall survival rates threefold over the past 10 years, without worsened neurological outcome among survivors. The overall survival rate remains under 50 percent, however. The study was published online Dec. 18 in Circulation: Cardiovascular Quality and Outcomes.

According to the study, cardiac arrest affects between 2 and 6 percent of all pediatric intensive care patients, with poor rates of survival and high rates of neurologic damage among survivors. In recent years, attempts to improve outcomes among these patients has led to initiatives directed toward early identification and management of at-risk patients, higher quality resuscitations, and multidisciplinary post-resuscitation care.   

Lead author Saket Girotra, MD, of University of Iowa Hospitals and Clinics in Iowa City, and colleagues used data from the GWTG-Resuscitation registry to identify temporal trends in pediatric cardiac arrest survival. They reviewed records of pediatric patients who experienced in-hospital cardiac arrest between Jan. 1, 2000 and Nov. 19, 2009. Citing “distinct clinical circumstances and outcomes with cardiac arrest” in emergency departments, operating rooms and procedural suites, the researchers excluded cardiac arrests that occurred in these locations from their analysis.

Their study sample was 1,031 patients from 12 hospitals, all of them urban teaching hospitals with pediatric residency or fellowship programs. The primary endpoint was survival to discharge. Secondary endpoints were acute resuscitation survival (return of spontaneous circulation for 20 minutes or more after initial arrest), post-resuscitation survival (survival to discharge among patients who survived resuscitation), and rates of significant neurological disability among survivors based on pediatric cerebral performance category (PCPC) scores (a PCPC score of 4 or higher was considered significant neurological disability).

Variables were age, gender, type of initial cardiac arrest rhythm pulseless electrical activity and asystole were considered together as nonshockable rhythms, while ventricular fibrillation and pulseless ventricular tachycardia were considered together as shockable rhythms.

Over time the characteristics of the patients in the study changed. Pulseless electrical activity led to the cardiac arrest in 26.6 percent of patients between 2000 and 2003, but increased to 70.3 percent between 2007 and 2009. The proportion of newborn patients increased over time, but the proportion of patients over 5 years of age decreased.

After adjusting for patient characteristics, the researchers found that survival to discharge increased from 14.3 percent in 2000 to 43.4 percent in 2009. The trends were similar between age groups, gender groups, and initial cardiac arrest rhythm. Post-resuscitation survival also improved significantly, from 42.9 percent in 2000 to 81.2 percent in 2009. There was no significant change in the percentage of survivors with serious neurological impairment.

The researchers concluded that the increased survival rates, despite increases in the proportion of cardiac arrests caused by nonshockable rhythms, were due to advances in resuscitative care. They noted that over time a higher proportion of the patients were in monitored units when cardiac arrest occurred, suggesting earlier and better identification of patients at risk, as well as faster response times.

Girotra et al pointed out that their study did not describe improvements at the hospital level and asserted that future studies are needed to identify site-level variations in survival. In addition, the GWTG-Resuscitation registry does not provide information needed to evaluate all the variables that may have led to improved outcomes. The study did not evaluate long-term survival because the registry does not provide that data, nor could the study evaluate rates of cardiac arrest, because data on pediatric admissions was lacking. Finally the authors suggested that data taken solely from hospitals participating in the GWTG-Resuscitation registry, a quality improvement program, may not be applicable to nonparticipating hospitals.