Over the past 2 decades, 1 in 20 children with cardiac disease in the intensive care unit have experienced in-hospital cardiac arrest (IHCA), but incidence of IHCA and mortality has been decreasing, suggesting that post-arrest care, use of extracorporeal membrane oxygenation (ECMO), and preventive intervention education are effective. These findings were published in the Journal of the American Medical Association Network Open.
Investigators aimed to evaluate incidence, trends, mortality, and associated IHCA factors in children in the intensive care unit (ICU) with cardiac disease. Primary outcomes included IHCA incidence and in-hospital mortality. Secondary outcomes included proportions of patients who received extracorporeal cardiopulmonary resuscitation (ECPR), ECMO, and patients not reaching return of spontaneous circulation (ROSC).
They initiated a systematic review and meta-analysis using EMBASE, Web of Science, CINAHL, and PubMed from inception to September 2021 searching for observational studies on IHCA in pediatric ICU patients with cardiac disease. There were 2 independent observers who included 25 studies (23 cohort studies, 2 case-control studies) in the systematic review (N=131,724 patients; ≤21 years of age) and 18 of the studies were included in a random effects meta-analysis. Meta-regression was used to assess trends in mortality and incidence.
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Studies that included a selected population (IHCA during intubation only), IHCA vs out-of-hospital CA, general hospitalized patients vs ICU patients, and that had inseparable mixed populations of children vs adults were excluded from review. Data was collected from the US in 20 studies and from Iran, Finland, UK, Australia, and Canada in the other 5 studies.
The investigators found that 5% (95% CI, 4%-6%) of children in the ICU with cardiac disease experience IHCA. Among these children, pooled in-hospital mortality was 51% (95% CI, 42%-59%). Among these children, 39% (95% CI, 29%-51%) did not reach ROSC. In the hospitals with ECMO, 22% of patients received ECPR (95% CI, 14%-33%). There were 22% (95% CI, 12%-38%) who could not be resuscitated. The pooled proportion of patients in studies with the last recruitment year before 2010 in-hospital mortality was 62% (95% CI, 41%-80%) and with the last recruitment year of 2010 or later it was 46% (95% CI, 37%-54%).
Investigators noted a significant decrease over the last 20 years in incidence of IHCA and associated in-hospital mortality, with random-effects meta-regression adjusting for study type and category of patients (both P trend =.90). The pooled proportion of patients in studies with the last recruitment year before 2010 experiencing IHCA was 7% (95% CI, 5%-8%) and with the last recruitment year of 2010 or later it was 3% (95% CI, 2%-4%). They found increased mortality odds and incidence of IHCA were associated with higher surgical complexity, prearrest mechanical ventilation or ECMO, arrhythmias, univentricular physiology, comorbidities, prematurity, and neonatal age. The proportion of patients not reaching ROSC did not change significantly over time (P trend=.90) in random-effects meta-regression adjusting for study type and category of patients.
Limitations of the study include a high and difficult-to-control heterogeneity of data, as well as no data regarding compliance with AHA guidelines. Additionally, definition of cardiac arrest varies among the included studies.
“ECMO has become an important resuscitation strategy in this high-risk population, with about one-quarter of patients undergoing ECPR in centers with expertise,” the study authors wrote. “Both the incidence of IHCA and associated in-hospital mortality have significantly decreased over time, suggesting that education on preventive measures, the use of ECMO, and post-arrest care, may have significantly improved outcomes.”
Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Reference
Sperotto F, Daverio M, Amigoni A, et al. Trends in in-hospital cardiac arrest and mortality among children with cardiac disease in the intensive care unit: a systematic review and meta-analysis. JAMA Netw Open. Published online February 10, 2023. doi:10.1001/jamanetworkopen.2022.56178
This article originally appeared on The Cardiology Advisor
