Timing and mode of death after pediatric in- and out-of-hospital cardiac arrest: a single center retrospective study

Aims: To characterize and compare modes of death and reasons for withdrawal of life-sustaining therapies (WLST) in children admitted to an intensive care unit (ICU) after in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). Methods: Single center retrospective study of children who experienced IHCA or OHCA, were admitted to an ICU from January 2017 to March 2023, and died prior to discharge. Modes of death were classified as: a) death by neurologic criteria (DNC), b) WLST, c) recurrent arrest with attempted resuscitation (“recurrent arrest”) or d) recurrent arrest without attempted resuscitation (“recurrent arrest/DNAR”). Results: Of 746 patients receiving post-arrest care, 260 non-survivors were analyzed. Of 155 IHCA patients, mode of death was DNC 8 (5%), WLST 87 (56%), recurrent arrest 33 (21%), recurrent arrest/DNAR 27 (18%). The primary reason for WLST was poor cardiovascular prognosis (WLST-CV) (40/87 [46%]). Of 105 OHCA patients, mode of death was DNC 51 (49%), WLST 38 (36%), recurrent arrest 8 (7.5%), recurrent arrest/DNAR 8 (7.5%). The primary reason for WLST was poor neurologic prognosis (WLST-N) (32/38 [84%]). Compared to OHCA patients, children with IHCA were less likely to die from DNC (p < 0.001) and more often underwent WLST-CV (p < 0.001). The median time to death was longer for IHCA vs. OHCA (5 [0.8,30] vs 3 [1.5,6] days, p = 0.03). Conclusions: Following an IHCA, non-survivors more frequently died from circulatory failure, including WLST-CV or recurrent arrest, while OHCA non-survivors more frequently died from neurologic injury, including DNC and WLST-N. Children who had an IHCA died later after their arrest than those who had an OHCA.