Severe intracranial hemorrhage or ischemia associated with unfavorable outcomes after pediatric in-hospital cardiac arrest

OBJECTIVE: To describe the association between severe intracranial hemorrhage or ischemia following pediatric in-hospital cardiac arrest (IHCA) and clinical outcomes.

DESIGN: Retrospective cohort study.

SETTING: ICUs that participated in the ICU-RESUS (NCT02837497) trial.

PATIENTS: Children enrolled in ICU-RESUS with return of circulation following IHCA who had a head computerized tomography (CT) within 7 days of cardiac arrest.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Radiology reports from CT scans post-IHCA were categorized for the presence ischemia and hemorrhage. The primary exposure was severe intracranial hemorrhage or ischemia, and the primary outcome was unfavorable neurologic outcome (defined as death or change in Pediatric Cerebral Performance Category ≥1 from baseline resulting in hospital discharge PCPC 4-5). Of the 1000 patients in ICU-RESUS with return of circulation, 180 had a CT, and 73 (40.5 %) had severe hemorrhage or ischemia. Patients with severe hemorrhage or ischemia had longer duration of CPR (33 [8-50] vs 12 [5-31] minutes, p < 0.001), more epinephrine doses (5 [2-14.5 vs 3 [2-8.5], p = 0.031), more often received eCPR (59 % vs 39 %, p = 0.010), had higher post-arrest lactate levels (mmol/L) (14.1 [9.3-19.6] vs 10.5 [6.3-15.3], p = 0.018) and lower post-arrest pH (7.1 [7-7.3] vs 7.2 [7.1-7.3), p = 0.003) than patients without severe hemorrhage or ischemia. Severe hemorrhage or severe ischemia was more common among patients with unfavorable compared to favorable outcome (56 % vs 21 %, p < 0.001). All 7 patients with severe hemorrhage and ischemia died.

CONCLUSIONS: The presence of severe intracranial hemorrhage or ischemia on head CT within the first 7 days post-IHCA was associated with unfavorable outcomes, and all patients with both died. However, severe hemorrhage or ischemia post-IHCA is not always a poor prognostic feature, as some patients do survive with favorable neurologic outcome. Neuroimaging findings should be taken in context with the rest of a patient's clinical course and not in isolation.