Division of Pediatric Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia.
Department of Pediatrics, University of Utah, Salt Lake City.
JAMA Pediatr. 2018 Feb 1;172(2):143-153. doi: 10.1001/jamapediatrics.2017.4043.
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 during targeted temperature management.
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.
Hypotension.
Survival to hospital discharge.
Of 292 children (194 boys [66.4%] and 98 girls [33.6%]; median age, 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) or rewarming (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).
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.
在美国，每年有超过 6000 名儿童发生院外心脏骤停 (OHCA)，幸存者的生存率不到 10%，且许多幸存者存在严重的神经功能障碍。心脏骤停后可能会出现低血压，但在目标温度管理期间，其发生频率及其与生存率的关系尚未得到很好的描述。
确定在接受 OHCA 复苏的儿童和青少年中，低血压是否与出院生存率相关。
设计、设置和参与者：这是儿科心脏骤停后治疗性低温（THAPCA）试验的事后二次分析，包括 36 个儿科重症监护病房在 2009 年 9 月 1 日至 2012 年 12 月 31 日期间治疗的 292 名年龄大于 48 小时且小于 18 岁的儿科患者。参与者接受了治疗性低温（33.0°C）与治疗性常温（36.8°C）治疗 48 小时。所有参与者在初始体温干预的前 6 小时内都有每小时收缩压测量记录。从体温干预开始时（时间 0）开始，对年龄、性别和身高进行了每小时血压的正常化。早期低血压定义为在体温干预后前 6 小时内收缩压低于第五百分位数。使用逐步向前逻辑回归，评估了感兴趣的协变量（年龄、性别、初始心脏节律、任何预先存在的疾病、心肺复苏（CPR）估计持续时间、心脏骤停的主要原因、体温干预组、夜间或周末心脏骤停、目击状态和旁观者 CPR）在最终模型中。数据于 2016 年 2 月 5 日至 2017 年 6 月 13 日进行分析。
低血压。
出院生存率。
在 292 名儿童（194 名男孩[66.4%]和 98 名女孩[33.6%]；中位数年龄，23.0 个月[四分位距，5.0-105.0 个月]）中，78 名（26.7%）至少发生过 1 次早期低血压。在诱导和维持（73 名[47.7%]与 139 名[51.8%]；P = .50）或在第一个 72 小时期间的复温（35 名[29.7%]与 95 名[20.0%]；P = .10）期间，治疗性低温组和治疗性常温组的低血压发生率无差异。发生早期低血压的患者出院生存率较低（20 名[25.6%]与 214 名[43.5%]；调整后的优势比，0.39；95%CI，0.20-0.74）。
在 THAPCA 试验的这一事后二次分析中，6 小时内有 26.7%的参与者出现体温干预后低血压。心脏骤停后早期低血压与出院生存率降低有关，即使在调整了感兴趣的协变量后也是如此。
