Pulmonary hypertension among children with in-hospital cardiac arrest: A multicenter study

Abstract

Aims

To determine the prevalence of pulmonary hypertension (PH) among children with in-hospital cardiac arrest (IHCA) and its association with survival.

Methods

Children (<18 years) admitted to ICUs participating in the Virtual Pediatric Systems multicenter registry between January 2011 and December 2017 who had an IHCA during their hospitalization were included. Patients were classified by whether they had a documented diagnosis of PH at the time of IHCA. Clinical characteristics were compared between patients with and without PH. After propensity score matching, conditional logistic regression within the matched cohort determined the association between PH and survival to hospital discharge.

Results

Of 18,575 children with IHCA during the study period, 1,590 (8.6%) had a pre-arrest diagnosis of PH. Patients with PH were more likely to be 29 days to 2 years of age, female, Black/African American, and American Indian/Alaskan Native, and to be treated in a cardiac ICU or mixed PICU/cardiac ICU. At ICU admission, PH patients had a lower probability of death as determined by the Pediatric Index of Mortality 2 (PIM-2) score. Patients with PH were more likely to be receiving inhaled nitric oxide (13.0% vs. 2.1%; p < 0.001). Propensity score matching successfully matched 1,302 PH patients with 3,604 non-PH patients. Patients with PH were less likely to survive to hospital discharge (aOR 0.83; 95% CI: 0.72–0.95; p = 0.01) than non-PH patients.

Conclusions

In this large multicenter study, 8.6% of children with IHCA had pre-existing documented PH. These children were less likely to survive to hospital discharge than those without PH.

Introduction

Among adults who suffer an in-hospital cardiac arrest (IHCA), pre-existing pulmonary hypertension (PH) is associated with dismal outcomes.¹ Laboratory data indicate that PH with elevated pulmonary vascular resistance (PVR) during cardiopulmonary resuscitation (CPR) decreases pulmonary blood flow, cardiac output, and coronary and cerebral perfusion.2., 3., 4. Hospitalized children with PH are at high risk of mortality and IHCA.5., 6., 7., 8. Thus, expert consensus postulates that PH-associated pediatric cardiac arrest portends poor outcomes,9, 10 but published data on pediatric IHCA associated with PH are limited.

In a recent small, retrospective study, 35% of children with IHCAs in the intensive care unit (ICU) had echocardiographic evidence of PH prior to cardiac arrest.¹¹ However, this study was limited to a single institution and did not identify an association between PH and cardiac arrest outcomes. Therefore, the objectives of the current study were to leverage a large, multicenter database to: 1) describe the prevalence of PH among children with IHCA and 2) compare survival outcomes between IHCA patients with and without pre-existing PH in a propensity matched cohort.