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Intra-arrest prognostic factors for cardiac arrest in infants and children

Question Type:
Prognostic
Full Question:
Among infants and children during cardiac arrest (P), does does the presence of any specific intra-arrest prognostic factors (I), compared with compared with the absence of these factors (C), change survival to 180 days with good neurological outcome, survival to 60 days with good neurological outcome, survival to hospital discharge with good neurological outcome, survival to 30 days with good neurological outcome, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year (O)?
Consensus on Science:
OHCA: Age Greater or Less Than 1 YearFor the important outcome of 30-day survival with good neurologic outcome, we identified low-quality evidence for prognostic significance (downgraded for serious risk of bias and upgraded for moderate effect size) from 1 pediatric observational study of OHCA (5158 subjects)(Kitamura 2010, 1347-1354) in which age greater than 1 year was associated with improved survival when compared with age less than 1 year (relative risk [RR], 2.4; 95% CI, 1.7–3.4).For the important outcome of 30-day survival, we identified very-low-quality evidence for prognostic significance (downgraded for serious risk of bias) from 1 pediatric observational study of OHCA (5158 subjects)(Kitamura 2010, 1347-1354) in which age greater than 1 year (versus age less than 1 year) was associated with improved survival (RR, 1.5; 95% CI, 1.3–1.8).For the important outcome of survival to hospital discharge, we identified low-quality evidence for prognostic significance (downgraded for serious imprecision and upgraded for moderate effect size) from 1 pediatric observational study of OHCA (621 subjects)(Atkins 2009, 1484-1491) in which age greater than 1 year (versus age less than 1 year) was significantly associated with improved outcome (RR, 2.7; 95% CI, 1.3–5.7). We identified very-low-quality evidence for prognostic significance (downgraded for very serious risk of bias and serious imprecision) from 2 pediatric observational OHCA studies(Young 2004, 157-164; Moler 2011, 141-149) enrolling a total of 738 children that failed to show any significant difference in outcomes in patients older than 1 year when compared with patients younger than 1 year (Young: RR, 1.3; 95% CI, 0.8–2.1; Moler: RR, 1.4; 95% CI, 0.8–2.4).OHCA: Shockable Versus Nonshockable RhythmsFor the important outcome of 30-day survival with good neurologic outcome, we identified low-quality evidence for prognostic significance (downgraded for serious risk of bias and upgraded for large effect size) from 1 pediatric observational study of OHCA (5170 subjects)(Kitamura 2010, 1347-1354) that found that VF as an initial rhythm compared with the combined rhythm group of pulseless electrical activity (PEA)/asystole was associated with improved survival (RR, 4.4; 95% CI, 3.6–5.3).For the important outcome of 30-day survival, we identified moderate-quality evidence for prognostic significance (downgraded for serious risk of bias and upgraded for large effect size) from 1 pediatric observational study of OHCA (5170 subjects)(Kitamura 2010, 1347-1354) that found that VF as an initial rhythm compared with the combined rhythm group of PEA/asystole was associated with improved survival (RR, 9.0; 95% CI, 6.7–12.3).For the important outcome of survival to hospital discharge, we identified very-low-quality evidence for prognostic significance (downgraded for very serious risk of bias and serious imprecision and upgraded for moderate effect size) from 2 pediatric observational studies of OHCA,(Atkins 2009, 1484-1491; Moler 2011, 141-149) enrolling a total 504 children, that found VF/VT as an initial rhythm was significantly associated with improved outcome compared with the combined rhythm group of PEA/asystole (Atkins(Atkins 2009, 1484-1491): RR, 4.0; 95% CI, 1.8–8.9; and Moler(Moler 2011, 141-149): RR, 2.7; 95% CI, 1.3–5.6). We identified very-low-quality evidence for prognostic significance (downgraded for very serious risk of bias) from 1 pediatric observational study of OHCA (548 subjects)(Young 2004, 157-164) that failed to show a survival difference between VF/VT as an initial rhythm when compared with the combined rhythm group of PEA/asystole (RR, 1.3; 95% CI, 0.5–3.0).OHCA: Duration of CPRFor the important outcome of survival to hospital discharge and survival to 1 year, we identified very-low-quality evidence for prognostic significance (downgraded for very serious risk of bias and serious imprecision and upgraded for large effect size) from 3 pediatric observational OHCA studies(Young 2004, 157-164; Lopez-Herce 2005, 807-815; Moler 2011, 141-149) enrolling a total of 833 children, showing a higher likelihood of survival with shorter duration of CPR. CPR for less than 20 minutes was associated with improved 1-year survival in 1 study (RR, 6.6; 95% CI, 2.9–14.9),(Lopez-Herce 2005, 807-815) while median durations of 16 (interquartile range [IQR], 10–30) and 19 (IQR, 3.5–28.5) minutes were associated with survival to hospital discharge in 2 studies.(Young 2004, 157-164; Moler 2011, 141-149) IHCA: Age Greater or Less Than 1 YearFor the important outcome of survival to hospital discharge, we identified low-quality evidence for prognostic significance from 1 pediatric observational IHCA study (3419 subjects)(Matos 2013, 442-451) that showed that age greater than 1 year when compared with age less than 1 year was associated with lower survival to discharge (RR, 0.7; 95% CI, 0.6–0.8). There was low-quality evidence (not downgraded) from 1 pediatric observational study(Lopez-Herce 2013, 309-318) of 502 subjects, and very-low-quality evidence (downgraded for very serious risk of bias and imprecision) from 2 pediatric observational IHCA studies(de Mos 2006, 1209-1215; Meert 2009, 544-553) enrolling a total of 444 children subjects, that did not show statistical significance to age greater than 1 year versus age less than 1 year.For the critical outcome of survival to hospital discharge with good neurologic outcome, there was very-low-quality evidence (downgraded for very serious risk of bias) for prognostic significance from 1 pediatric observational IHCA study (464 subjects)(Meaney 2006, 2424-2433) that did not show a difference for age greater than 1 year when compared with age less than 1 year (RR, 0.7; 95% CI, 0.4–1.0).IHCA: Shockable Versus Nonshockable RhythmsFor the important outcome of survival to hospital discharge, there was low-quality evidence (not downgraded) for prognostic significance from 1 pediatric observational IHCA study (280 subjects)(Lopez-Herce 2013, 309-318) showing that the presence of an initial arrest rhythm of VF/pVT when compared with asystole/PEA was associated with improved outcomes (RR, 1.6; 95% CI, 1.1–2.4). There was low-quality evidence (not downgraded) for prognostic significance from 1 pediatric observational study(Matos 2013, 442-451) (2903 subjects) that did not show statistical significance to the initial arrest rhythm (RR, 1.1; 95% CI, 1.0–1.3).For the important outcome of 1-year survival, there was very-low-quality evidence (downgraded for very serious risk of bias and imprecision) for prognostic significance from 1 pediatric observational IHCA study (37 subjects)(Tibballs 2006, 310-318) that the initial arrest rhythm of VF/pVT when compared with asystole/PEA was not statistically significant (RR, 2.2; 95% CI, 0.7–6.5).IHCA: Duration of CPRFor the important outcome of 30-day survival, there was very-low-quality evidence (downgraded for very serious risk of bias and imprecision) for prognostic significance from 1 pediatric observational IHCA study (129 subjects)(Reis 2002, 200-209) that showed shorter duration of resuscitation events was associated with improved outcomes (adjusted relative risk [aRR], 0.95; 95% CI, 0.91–0.98 for each elapsed minute of CPR).For the important outcome of survival to hospital discharge, there was very-low-quality evidence (downgraded for very serious risk of bias and imprecision) for prognostic significance from 1 observational study of pediatric IHCA (103 subjects)(Haque 2011, 1356-1360) that showed shorter duration of resuscitation events was associated with improved survival (aRR, 5.8; 95% CI, 1.3–25.5). Low-quality evidence (not downgraded) from 1 observational study of pediatric IHCA (3419 subjects)(Matos 2013, 442-451) showed shorter duration of resuscitation events was associated with improved survival (10 [IQR, 4–25] minutes versus 25 [IQR, 12–45] minutes). This same study found significantly improved outcomes for surgical cardiac patients compared with general medical patients for all durations of resuscitation times (OR range, 2.2–3.7). Very-low-quality evidence (downgraded for very serious risk of bias) from 1 observational study of pediatric IHCA (330 subjects)(Meert 2009, 544-553) showed shorter duration of resuscitation events was associated with improved survival (8 [IQR, 3–19] minutes versus 13 [IQR, 5–31] minutes). Very-low-quality evidence (downgraded for imprecision) from 1 observational study of pediatric IHCA (451 subjects),(Lopez-Herce 2013, 309-318) when comparing resuscitation durations of less than 20 minutes to greater than 20 minutes, failed to show outcome differences that were statistically significant (RR, 0.8; 95% CI, 0.3–2.1).For the critical outcome of survival to hospital discharge with good neurologic outcome, there was low-quality evidence from 1 observational study of pediatric IHCA (3419 subjects)(Matos 2013, 442-451) that showed that shorter duration of resuscitation was associated with improved survival to discharge with good neurologic outcome among surgical cardiac patients when compared with general medical patients for all durations of resuscitation times (OR range, 2.0–3.3).We did not identify enough evidence to address the critical outcomes of survival to 180 days with good neurologic outcome, or survival to 60 days with good neurologic outcome.We did not identify any evidence to address the important outcomes of survival only at 60 days, 180 days.
Treatment Recommendation:
We suggest that for infants and children in cardiac arrest in the in-hospital setting, the use of predictors of positive patient outcome, such as patient age less than 1 year and the initial presence of a shockable rhythm, be used to assist prognostic decisions (weak recommendation, very-low-quality evidence for prognostic significance).We suggest that for infants and children in cardiac arrest in the out-of-hospital setting, the use of predictors of positive patient outcome, such as age greater than 1 year or VF/pVT as an initial rhythm, be considered to assist prognostic decisions (weak recommendation, very-low-quality evidence for prognostic significance).The confidence in estimates for the use of duration of resuscitation as a predictor of patient outcome in the in- or out-of-hospital setting is so low that the panel decided a recommendation was too speculative. Values, Preferences, and Task Force Insights In making this recommendation, we value the potential for individual children to have functional outcomes from cardiac arrest, despite the presence of individual poor prognostic factors, over the certainty of death associated with premature cessation of resuscitative efforts. We note that the measurement and reporting of quality of CPR, in addition to duration of CPR, confounds the attempt to define a cutoff duration. It is prudent for clinicians to use multiple patient factors and clinical observations and tests to help guide prognostication and decision-making during resuscitation, to avoid “self-fulfilling prophecies” of futility.
CoSTR Attachments:
Peds 814 combined document 1.20.15_n.docx    
Peds 814 Risk of bias 1.20.15_n.xlsx    

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