Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial

Alexis A. Topjian, Frank W. Moler, Russell Telford, Richard Holubkov, Vinay M. Nadkarni, Robert A. Berg, J. Michael Dean, Kathleen L. Meert, Jamie S. Hutchinson, Christopher J.L. Newth, Kimberly S. Bennett, John T. Berger, Jose A. Pineda, Joshua D. Koch, Charles L. Schleien, Heidi J. Dalton, George Ofori-Amanfo, Denise M. Goodman, Ericka L. Fink, Patrick McQuillen & 24 others Jerry J. Zimmerman, Neal J. Thomas, Elise W. Van Der Jagt, Melissa B. Porter, Michael T. Meyer, Rick Harrison, Nga Pham, Adam J. Schwarz, Jeffrey E. Nowak, Jeffrey Alten, Derek S. Wheeler, Utpal S. Bhalala, Karen Lidsky, Eric Lloyd, Mudit Mathur, Samir Shah, Theodore Wu, Andreas A. Theodorou, Ronald C. Sanders, Faye S. Silverstein, James R Christensen, Beth S Slomine, Victoria L. Pemberton, Brittan Browning

Research output: Contribution to journalArticle

Abstract

IMPORTANCE Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described duringtargeted temperature management. OBJECTIVE To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1,2009, through December 31,2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5,2016, through June 13,2017. EXPOSURES Hypotension. MAIN OUTCOMES AND MEASURE Survival to hospital discharge. RESULTS Of 292children (194 boys [66.4%] and 98 girls [33.6%]; medianage, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) orre warming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74). CONCLUSIONS AND RELEVANCE In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.

Original languageEnglish (US)
Pages (from-to)143-153
Number of pages11
JournalJAMA Pediatrics
Volume172
Issue number2
DOIs
StatePublished - Feb 1 2018

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Out-of-Hospital Cardiac Arrest
Pediatric Hospitals
Hypotension
Randomized Controlled Trials
Heart Arrest
Temperature
Survival
Induced Hypothermia
Blood Pressure
Cardiopulmonary Resuscitation
Pediatrics
Pediatric Intensive Care Units
Preexisting Condition Coverage
Resuscitation
Nervous System
Survivors
Survival Rate
Logistic Models
Odds Ratio
Maintenance

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial. / Topjian, Alexis A.; Moler, Frank W.; Telford, Russell; Holubkov, Richard; Nadkarni, Vinay M.; Berg, Robert A.; Dean, J. Michael; Meert, Kathleen L.; Hutchinson, Jamie S.; Newth, Christopher J.L.; Bennett, Kimberly S.; Berger, John T.; Pineda, Jose A.; Koch, Joshua D.; Schleien, Charles L.; Dalton, Heidi J.; Ofori-Amanfo, George; Goodman, Denise M.; Fink, Ericka L.; McQuillen, Patrick; Zimmerman, Jerry J.; Thomas, Neal J.; Van Der Jagt, Elise W.; Porter, Melissa B.; Meyer, Michael T.; Harrison, Rick; Pham, Nga; Schwarz, Adam J.; Nowak, Jeffrey E.; Alten, Jeffrey; Wheeler, Derek S.; Bhalala, Utpal S.; Lidsky, Karen; Lloyd, Eric; Mathur, Mudit; Shah, Samir; Wu, Theodore; Theodorou, Andreas A.; Sanders, Ronald C.; Silverstein, Faye S.; Christensen, James R; Slomine, Beth S; Pemberton, Victoria L.; Browning, Brittan.

In: JAMA Pediatrics, Vol. 172, No. 2, 01.02.2018, p. 143-153.

Research output: Contribution to journalArticle

Topjian, AA, Moler, FW, Telford, R, Holubkov, R, Nadkarni, VM, Berg, RA, Dean, JM, Meert, KL, Hutchinson, JS, Newth, CJL, Bennett, KS, Berger, JT, Pineda, JA, Koch, JD, Schleien, CL, Dalton, HJ, Ofori-Amanfo, G, Goodman, DM, Fink, EL, McQuillen, P, Zimmerman, JJ, Thomas, NJ, Van Der Jagt, EW, Porter, MB, Meyer, MT, Harrison, R, Pham, N, Schwarz, AJ, Nowak, JE, Alten, J, Wheeler, DS, Bhalala, US, Lidsky, K, Lloyd, E, Mathur, M, Shah, S, Wu, T, Theodorou, AA, Sanders, RC, Silverstein, FS, Christensen, JR, Slomine, BS, Pemberton, VL & Browning, B 2018, 'Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial', JAMA Pediatrics, vol. 172, no. 2, pp. 143-153. https://doi.org/10.1001/jamapediatrics.2017.4043
Topjian, Alexis A. ; Moler, Frank W. ; Telford, Russell ; Holubkov, Richard ; Nadkarni, Vinay M. ; Berg, Robert A. ; Dean, J. Michael ; Meert, Kathleen L. ; Hutchinson, Jamie S. ; Newth, Christopher J.L. ; Bennett, Kimberly S. ; Berger, John T. ; Pineda, Jose A. ; Koch, Joshua D. ; Schleien, Charles L. ; Dalton, Heidi J. ; Ofori-Amanfo, George ; Goodman, Denise M. ; Fink, Ericka L. ; McQuillen, Patrick ; Zimmerman, Jerry J. ; Thomas, Neal J. ; Van Der Jagt, Elise W. ; Porter, Melissa B. ; Meyer, Michael T. ; Harrison, Rick ; Pham, Nga ; Schwarz, Adam J. ; Nowak, Jeffrey E. ; Alten, Jeffrey ; Wheeler, Derek S. ; Bhalala, Utpal S. ; Lidsky, Karen ; Lloyd, Eric ; Mathur, Mudit ; Shah, Samir ; Wu, Theodore ; Theodorou, Andreas A. ; Sanders, Ronald C. ; Silverstein, Faye S. ; Christensen, James R ; Slomine, Beth S ; Pemberton, Victoria L. ; Browning, Brittan. / Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial. In: JAMA Pediatrics. 2018 ; Vol. 172, No. 2. pp. 143-153.
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abstract = "IMPORTANCE Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10{\%} and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described duringtargeted temperature management. OBJECTIVE To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1,2009, through December 31,2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5,2016, through June 13,2017. EXPOSURES Hypotension. MAIN OUTCOMES AND MEASURE Survival to hospital discharge. RESULTS Of 292children (194 boys [66.4{\%}] and 98 girls [33.6{\%}]; medianage, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7{\%}) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7{\%}] vs 72 of 139 [51.8{\%}]; P = .50) orre warming (35 of 118 [29.7{\%}] vs 19 of 95 [20.0{\%}]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6{\%}] vs 93 of 214 [43.5{\%}]; adjusted odds ratio, 0.39; 95{\%} CI, 0.20-0.74). CONCLUSIONS AND RELEVANCE In this post hoc secondary analysis of the THAPCA trial, 26.7{\%} of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.",
author = "Topjian, {Alexis A.} and Moler, {Frank W.} and Russell Telford and Richard Holubkov and Nadkarni, {Vinay M.} and Berg, {Robert A.} and Dean, {J. Michael} and Meert, {Kathleen L.} and Hutchinson, {Jamie S.} and Newth, {Christopher J.L.} and Bennett, {Kimberly S.} and Berger, {John T.} and Pineda, {Jose A.} and Koch, {Joshua D.} and Schleien, {Charles L.} and Dalton, {Heidi J.} and George Ofori-Amanfo and Goodman, {Denise M.} and Fink, {Ericka L.} and Patrick McQuillen and Zimmerman, {Jerry J.} and Thomas, {Neal J.} and {Van Der Jagt}, {Elise W.} and Porter, {Melissa B.} and Meyer, {Michael T.} and Rick Harrison and Nga Pham and Schwarz, {Adam J.} and Nowak, {Jeffrey E.} and Jeffrey Alten and Wheeler, {Derek S.} and Bhalala, {Utpal S.} and Karen Lidsky and Eric Lloyd and Mudit Mathur and Samir Shah and Theodore Wu and Theodorou, {Andreas A.} and Sanders, {Ronald C.} and Silverstein, {Faye S.} and Christensen, {James R} and Slomine, {Beth S} and Pemberton, {Victoria L.} and Brittan Browning",
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T1 - Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial

AU - Topjian, Alexis A.

AU - Moler, Frank W.

AU - Telford, Russell

AU - Holubkov, Richard

AU - Nadkarni, Vinay M.

AU - Berg, Robert A.

AU - Dean, J. Michael

AU - Meert, Kathleen L.

AU - Hutchinson, Jamie S.

AU - Newth, Christopher J.L.

AU - Bennett, Kimberly S.

AU - Berger, John T.

AU - Pineda, Jose A.

AU - Koch, Joshua D.

AU - Schleien, Charles L.

AU - Dalton, Heidi J.

AU - Ofori-Amanfo, George

AU - Goodman, Denise M.

AU - Fink, Ericka L.

AU - McQuillen, Patrick

AU - Zimmerman, Jerry J.

AU - Thomas, Neal J.

AU - Van Der Jagt, Elise W.

AU - Porter, Melissa B.

AU - Meyer, Michael T.

AU - Harrison, Rick

AU - Pham, Nga

AU - Schwarz, Adam J.

AU - Nowak, Jeffrey E.

AU - Alten, Jeffrey

AU - Wheeler, Derek S.

AU - Bhalala, Utpal S.

AU - Lidsky, Karen

AU - Lloyd, Eric

AU - Mathur, Mudit

AU - Shah, Samir

AU - Wu, Theodore

AU - Theodorou, Andreas A.

AU - Sanders, Ronald C.

AU - Silverstein, Faye S.

AU - Christensen, James R

AU - Slomine, Beth S

AU - Pemberton, Victoria L.

AU - Browning, Brittan

PY - 2018/2/1

Y1 - 2018/2/1

N2 - IMPORTANCE Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described duringtargeted temperature management. OBJECTIVE To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1,2009, through December 31,2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5,2016, through June 13,2017. EXPOSURES Hypotension. MAIN OUTCOMES AND MEASURE Survival to hospital discharge. RESULTS Of 292children (194 boys [66.4%] and 98 girls [33.6%]; medianage, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) orre warming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74). CONCLUSIONS AND RELEVANCE In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.

AB - IMPORTANCE Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described duringtargeted temperature management. OBJECTIVE To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1,2009, through December 31,2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5,2016, through June 13,2017. EXPOSURES Hypotension. MAIN OUTCOMES AND MEASURE Survival to hospital discharge. RESULTS Of 292children (194 boys [66.4%] and 98 girls [33.6%]; medianage, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) orre warming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74). CONCLUSIONS AND RELEVANCE In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.

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