Introduction
Methods
Results
Post-ROSC factors associated with mortality
Number of patients | Non-survivors | Survivors | P -value | |
---|---|---|---|---|
Median (IQR) | Median (IQR) | |||
Gasometry at 1 h
| ||||
pH | 259 | 7.23 (7.03 to 7.35) | 7.29 (7.17 to 7.38) |
0.004
|
PaO2, mmHg | 253 | 78.5 (45.0 to 125.0) | 81.0 (47.0 to 136.0) | 0.476 |
PaO2/FiO2 | 231 | 85.5 (50.75 to 189.5) | 111 (63 to 242) | 0.101 |
PaCO2, mmHg | 255 | 46 (32 to 63) | 42 (34 to 52) | 0.314 |
HCO3 mEq/L | 241 | 18 (12.0 to 24.5) | 21 (15 to 25) | 0.064 |
BE | 233 | -8 (-2 to -15) | -6 (-0.75 to -12) |
0.049
|
Lactic acid, mmol/L | 136 | 7.2 (7 to 13) | 4.1 (1.89 to 8) |
0.002
|
FiO2 | 249 | 100 (72.5 to 100) | 100 (50 to 100) |
0.034
|
Gasometry at 24 h
| ||||
pH | 209 | 7.35 (7.26 to 7.42) | 7.40 (7.34 to 7.45) |
0.001
|
PaO2, mmHg | 205 | 77 (50 to 124) | 82 (49.75 to 119.25) | 0.924 |
PaO2/FiO2 | 178 | 125 (70.25 to 242.08) | 111 (63 to 242) |
0.031
|
PaCO2, mmHg | 208 | 42.5 (34.25 to 53.5) | 41 (35 to 46) | 0.175 |
HCO3, mEq/L | 205 | 22 (19 to 27) | 25 (21 to 29) |
0.009
|
BE | 186 | -2 (-5 to 3.1) | 1 (-3 to 5) |
0.031
|
Lactic acid, mmol/L | 123 | 2 (1.2 to 6.47) | 1.4 (0.9 to 2.25) |
0.007
|
FiO2 | 191 | 80(50 to 100) | 45 (30 to 65) |
0.001
|
Lactic acid clearance, % | 99 | 60 (25 to 75) | 68.63 (27.81 to 84.70) |
0.385
|
Mechanical ventilation after ROSC, %
| 215 | 94.4 | 93.5 | 0.756 |
Vasoactive treatment
| ||||
Patients with vasopressors after ROSC, % | 173 | 76.3 | 63.9 |
0.039
|
Inotropic score after ROSC | 154 | 80.7 (121.6) | 38.3 (78.7) |
0.001
|
Length of stay
| ||||
Days in the PICU | 224 | 7.9 (14.7) | 17.4 (19.4) |
0.001
|
Days in hospital ward | 118 | 4.5 (6.9) | 17.3 (19.4) |
0.001
|
Patients, number | Patients, % | Mortality, % | Odds ratio | 95% CI | P -value | |
---|---|---|---|---|---|---|
Mechanical ventilation
| ||||||
No | 42 | 6.1 | 41.2 | 1 | ||
Yes | 173 | 93.9 | 45 | 3.273 | 0.713 to 15.027 | 0.127 |
Vasoactive drugs
| ||||||
No | 79 | 31.3 | 29.1 | 1 | ||
Yes | 173 | 68.7 | 42.8 | 1.820 | 1.028 to 3.222 |
0.040
|
Vasoactive-inotropic score
| ||||||
<14 | 62 | 40.3 | 29 | 0.390 | ||
>14 | 92 | 59.7 | 51 | 2.564 | 1.288 to 5.050 |
0.007
|
Electrocardiographic rhythm after ROSC
| ||||||
Sinus rhythm | 230 | 72.8 | 43.5 | 1 | ||
Other rhythms | 86 | 27.2 | 53.5 | 1.495 | 0.909 to 2.459 | 0.113 |
Recovery of spontaneous breathing
| ||||||
Yes | 86 | 26 | 22.1 | 1 | ||
No | 245 | 74 | 57.1 | 4.694 | 2.659 to 8.333 |
0.001
|
pH 1 h
| ||||||
7.30 to 7.50 | 96 | 37.1 | 37.5 | 1 | ||
<7.30 | 154 | 59.5 | 48.7 | 1.582 | 0.941 to 2.662 | 0.084 |
>7.50 | 9 | 3.5 | 22.2 | 0.476 | 0.094 to 2.418 | 0.371 |
PaO
2
1 h
| ||||||
60 to 200 mmHg | 123 | 48.6 | 44.7 | 1 | ||
<60 mmHg | 96 | 37.9 | 43.8 | 0.962 | 0.562 to 1.646 | 0.887 |
>200 mmHg | 34 | 13.4 | 32.4 | 0.591 | 0.265 to 1.318 | 0.199 |
PaCO
2
1 h
| ||||||
30 to 50 mmHg | 133 | 52.2 | 33.1 | 1 | ||
<30 mmHg | 37 | 14.5 | 62.2 | 3.323 | 1.560 to 7.079 |
0.002
|
>50 mmHg | 85 | 33.3 | 52.9 | 2.276 | 1.302 to 3.978 |
0.004
|
CO
3
H 1 h
| ||||||
20 to 26 mEq/L | 75 | 31.1 | 36 | 1 | ||
<20 mEq/L | 118 | 49 | 46.6 | 1.552 | 0.857 to 2.812 | 0.147 |
>26 mEq/L | 48 | 19.9 | 41.7 | 1.27 | 0.604 to 2.669 | 0.528 |
Base excess 1 h
| ||||||
+4 to -4 | 48 | 20.6 | 37.5 | 1 | ||
<-4 | 154 | 66.1 | 46.8 | 1.463 | 0.753 to 2.844 | 0.261 |
> + 4 | 31 | 13.3 | 41.9 | 1.204 | 0.479 to 3.027 | 0.694 |
FiO
2
1 h
| ||||||
<0.50 | 42 | 16.7 | 12.1 | 1 | ||
0.50 to 0.79 | 41 | 16.3 | 12.9 | 1.150 | 0.468 to 2.847 | 0.756 |
≥0.80 | 169 | 67.1 | 75 | 2.120 | 1.044 to 4.311 |
0.038
|
PaO
2
/FiO
2
1 h
| ||||||
>300 | 166 | 16.7 | 45.5 | 1 | ||
200 to 300 | 37 | 11.7 | 25.8 | 0.417 | 0.154 to 1.134 | 0.087 |
<200 | 28 | 71.6 | 46 | 1.024 | 0.530 to 1.978 | 0.945 |
Lactic acid 1 h
| ||||||
<2 mmol/L | 27 | 19.9 | 22.2 | 1 | ||
2 to 5 mmol/L | 39 | 28.7 | 28.2 | 1.375 | 0.438 to 4.318 | 0.585 |
>5 mmol/L | 70 | 51.5 | 51.4 | 3.706 | 1.335 to 10.29 |
0.012
|
pH 24 h
| ||||||
7.30 to 7.50 | 158 | 75.6 | 27.8 | 1 | ||
<7.30 | 39 | 18.7 | 53.8 | 3.023 | 1.472 to 6.205 |
0.003
|
>7.50 | 70 | 5.7 | 33.3 | 1.295 | 0.371 to 4.520 | 0.685 |
PaO
2
24 h
| ||||||
60 to 200 mmHg | 121 | 59 | 32.2 | 1 | ||
<60 mmHg | 70 | 34.1 | 28.6 | 0.841 | 0.442 to 1.601 | 0.598 |
>200 mmHg | 14 | 6.8 | 57.1 | 2.803 | 0.910 to 8.636 | 0.073 |
PaCO
2
24 h
| ||||||
30 to 50 mmHg | 123 | 68.3 | 25.2 | 1 | ||
<30 mmHg | 14 | 7.8 | 35.7 | 1.649 | 0.513 to 5.294 | 0.401 |
>50 mmHg | 43 | 23.9 | 51.2 | 3.109 | 1.508 to 6.409 |
0.002
|
CO
3
H 24 h
| ||||||
20 to 26 mEq/L | 90 | 43.9 | 36.7 | 1 | ||
<20 mEq/L | 41 | 20 | 43.9 | 1.352 | 0.638 to 2,865 | 0.432 |
>26 mEq/L | 74 | 36.1 | 24.3 | 0.555 | 0.281 to 1,099 | 0.091 |
Base excess 24 h
| ||||||
+4 to -4 | 90 | 48.4 | 30 | 1 | ||
<-4 | 52 | 28 | 40.4 | 1.581 | 0.774 to 3.229 | 0.209 |
> + 4 | 44 | 23.7 | 22.7 | 0.686 | 0.297 to 1.585 | 0.378 |
FiO
2
24 h
| ||||||
<0.50 | 80 | 41.9 | 22.1 | |||
0.50 to 0.79 | 48 | 25.1 | 25 | 2.376 | 1.051 to 5.371 |
0.038
|
≥0.80 | 63 | 33 | 52.9 | 5.778 | 2.726 to 12.245 |
0.001
|
PaO
2
/FiO
2
24 h
| ||||||
>300 | 116 | 18.2 | 21.6 | 1 | ||
200 to 300 | 34 | 16.3 | 30.3 | 2.327 | 0.988 to 5.481 | 0.053 |
< 00 | 28 | 65.5 | 39.1 | 1.576 | 0.536 to 4.636 | 0.408 |
Lactic acid 24 h
| ||||||
<2 mmol/L | 73 | 59.3 | 23.3 | 1 | ||
2 to 5 mmol/L | 29 | 23.6 | 37.9 | 2.013 | 0.798 to 5.081 | 0.139 |
>5 mmol/L | 21 | 17.1 | 47.6 | 2.995 | 1.086 to 8.254 |
0.034
|
Lactic acid clearance
| ||||||
>50% | 56 | 55.9 | 28.8 | 1 | ||
>50% | 43 | 44.1 | 30.8 | 1.099 | 0.497 to 2.433 | 0.841 |
Odds ratio | 95% CI | P -value | |
---|---|---|---|
1 hour after return of spontaneous circulation
| |||
PaCO2 < 30 mmHg | 2.640 | 1.190 to 5.857 | 0.017 |
PaCO2 > 50 mmHg | 1.950 | 1.063 to 3.576 | 0.031 |
Lactic acid >5 mmol/L | 2.021 | 0.926 to 4.413 | 0.077 |
Vasoactive-inotropic score >14 | 2.454 | 1.252 to 4.810 | 0.009 |
24 hours after ROSC
| |||
PaCO2 > 50 mmHg | 2.541 | 1.156 to 5.587 | 0.020 |
FiO2 ≥ 0.80 | 3.864 | 1.698 to 8.794 | 0.001 |
Vasoactive-inotropic score >14 | 2.070 | 1.008 to 4.249 | 0.047 |
Post-ROSC factors associated with neurological outcome
PCPC 1 to 2 | PCPC >2 | P -value | |
---|---|---|---|
Mean (SD) | Mean (SD) | ||
Gasometry 1 h
| |||
pH | 7.29 (0.14) | 7.24 (0.17) | 0.120 |
PaO2, mmHg | 118.0 (104.9) | 88.3 (58.8) | 0.330 |
PaO2/FiO2 | 175.1 (143.1) | 121.2 (89.8) | 0.111 |
PaCO2, mmHg | 46.1 (14.5) | 45.6 (19.4) | 0.297 |
CO3H mEq/L | 21.8 (6.9) | 19.1 (7.4) |
0.025
|
Base excess | -3.4 (9.6) | -7.1 (9.4) |
0.042
|
Lactic acid, mmol/L | 5.8 (11.3) | 8.1 (6.5) |
0.003
|
FiO2 | 77.9 (27.8) | 76.8 (26.8) | 0.867 |
Gasometry 24 h
| |||
pH | 7.39 (0.08) | 7.39 (0.12) | 0.546 |
PaO2, mmHg | 96.7 (66.0) | 77.4 (40.3) | 0.094 |
PaO2/FiO2 | 207.1 (132.7) | 162.5 (119.8) | 0.053 |
PaCO2, mmHg | 42.7 (10.7) | 43.8 (13.1) | 0.681 |
CO3H, mEq/L | 25.2 (5.0) | 26.2 (6.7) | 0.389 |
Base excess | 0.6 (5.2) | 1.5 (7.7) | 0.710 |
Lactic acid, mmol/L | 2.2 (2.9) | 6.8 (20.7) | 0.405 |
FiO2 | 53.3 (24.4) | 57.9 (26.4) | 0.425 |
Lactic acid clearance, % | 37.1 (81.9) | 72.6 (19.2) |
0.009
|
Mechanical ventilation, %
| 94.4 | 97.4 | 0.667 |
Vasoactive treatment
| |||
Patients with pressors after ROSC, % | 57.9 | 77.5 |
0.033
|
Inotropic score after ROSC | 45.3 (78.4) | 36.4 (52.6) | 0.693 |
Patients with dopamine, % | 34 | 43.2 | 0.349 |
Dopamine dose, mcg/kg/min | 9.4 (4.9) | 10.7 (5.9) | 0.518 |
Patients with dobutamine, % | 19 | 40.9 |
0.007
|
Dobutamine dose, mcg/kg/min | 13.7 (8.1) | 9.2 (4.9) | 0.070 |
Patients with adrenaline, % | 20 | 18.2 | 1.000 |
Adrenaline dose, mcg/kg/min | 0.6 (0.6) | 0.4 (0.1) | 0.667 |
Patients with noradrenaline, % | 12 | 13.6 | 0.789 |
Noradrenaline dose, mcg/kg/min | 0.8 (0.7) | 1.3 (0.9) | 0.312 |
Patients with milrinone, % | 20 | 11.4 | 0.241 |
Milrinone dose, mcg/kg/min | 0.8 (0.2) | 0.8 (0.3) | 0.812 |
Length of stay
| |||
Days in the Pediatric ICU | 17.3 (17.9) | 22.3 (24.6) | 0.610 |
Days in hospital ward | 16.3 (18.1) | 21.0 (26.0) | 0.648 |
Patients, % | PCPC >2, % | Odds ratio | 95% CI | P -value | |
---|---|---|---|---|---|
Patients
| |||||
Mechanical ventilation
| |||||
No | 4.7 | 16.7 | 1.000 | ||
Yes | 95.3 | 30.9 | 2.235 | 0.252 to 19.791 | 0.470 |
Vasoactive drugs
| |||||
No | 42.1 | 18.4 | 1.000 | ||
Yes | 57.9 | 36 | 1.739 | 0.793 to 3.186 | 0.167 |
Adrenaline
| |||||
No | 80.6 | 31 | 1.000 | ||
Yes | 19.4 | 28.6 | 0.889 | 0.358 to 2.207 | 0.800 |
Noradrenaline
| |||||
No | 87.5 | 30.2 | 1.000 | ||
Yes | 12.5 | 33.3 | 1.158 | 0.405 to 3.313 | 0.785 |
Dopamine
| |||||
No | 63.2 | 27.5 | 1.000 | ||
Yes | 36.8 | 35.8 | 1.475 | 0.714 to 3.049 | 0.294 |
Dobutamine
| |||||
No | 74.3 | 24.3 | 1.000 | ||
Yes | 25.7 | 48.6 | 2.951 | 1.351 to 6.448 |
0.007
|
Milrinone
| |||||
No | 82.6 | 32.8 | 1.000 | ||
Yes | 17.4 | 20 | 0.513 | 0.179 to 1.469 | 0.213 |
Vasoactive-inotropic score
| |||||
<14 | 48.1 | 43.2 | 1.000 | ||
>14 | 51.9 | 35 | 0.707 | 0.282 to 1.772 | 0.459 |
Echocardiographic rhythm after ROSC
| |||||
Sinus rhythm | 74 | 27.8 | 1.000 | ||
Other rhythms | 26 | 36.8 | 1.497 | 0.685 to 3.274 | 0.312 |
Recovery of spontaneous breathing
| |||||
Yes | 65.3 | 25.5 | 1.000 | ||
No | 34.7 | 33.3 | 1.340 | 0.648 to 2.767 | 0.430 |
pH 1 h
| |||||
7.30 to 7.50 | 40.8 | 21.6 | 1.000 | ||
<7.30 | 54.4 | 32.4 | 1.739 | 0.752 to 4.023 | 0.196 |
>7.50 | 4.8 | 33.3 | 1.818 | 0.293 to 11.265 | 0.521 |
PaO
2
1 h
| |||||
60 to 200 mmHg | 45.2 | 33.3 | 1.000 | ||
<60 mmHg | 40.5 | 29.4 | 0.833 | 0.368 to 1.885 | 0.661 |
>200 mmHg | 14.3 | 16.7 | 0.400 | 0.103 to 1.553 | 0.186 |
PaCO
2
1 h
| |||||
30 to 50 mmHg | 62.1 | 23.4 | 1.000 | ||
<30 mmHg | 9.7 | 50 | 3.278 | 0.940 to 11.425 | 0.062 |
>50 mmHg | 28.2 | 37.1 | 1.937 | 0.815 to 4.601 | 0.134 |
CO
3
H 1 h
| |||||
20 to 26 mEq/L | 34.7 | 23.8 | 1.000 | ||
<20 mEq/L | 44.6 | 38.9 | 2.036 | 0.831 to 4.991 | 0.120 |
>26 mEq/L | 20.7 | 20 | 0.800 | 0.239 to 2.683 | 0.718 |
BE
| |||||
+4 to -4 | 24.8 | 25 | 1.000 | ||
<-4 | 61.1 | 33.3 | 1.500 | 0.557 to 4.041 | 0.423 |
> + 4 | 14.2 | 18.8 | 0.692 | 0.152 to 3.163 | 0.635 |
FiO
2
1 h
| |||||
<0.50 | 50.9 | 25.5 | 1.000 | ||
0.50 to 0.79 | 25.9 | 32.1 | 1.125 | 0.324 to 3.909 | 0.853 |
≥0.80 | 23.1 | 44 | 1.125 | 0.409 to 3.097 | 0.820 |
PaO
2
/FiO
2
1 h
| |||||
>300 | 15.9 | 16.7 | 1.000 | ||
200 to 300 | 12.4 | 14.3 | 3.049 | 0.083 to 11.149 | 0.092 |
<200 | 71.7 | 34.6 | 1.286 | 0.224 to 7.370 | 0.778 |
Lactic acid 1 h
| |||||
<2 mmol/L | 21.3 | 6.2 | 1.000 | ||
2 to 5 mmol/L | 37.3 | 25 | 3.520 | 0.675 to 18.366 | 0.135 |
>5 mmol/L | 41.3 | 41.9 | 9.263 | 1.883 to 45.560 |
0.006
|
pH 24 h
| |||||
7.30 to 7.50 | 80.6 | 26 | 1.000 | ||
<7.30 | 12.9 | 43.8 | 2.214 | 0.749 to 6.545 | 0.151 |
>7.50 | 6.5 | 62.5 | 4.744 | 1.059 to 21.248 |
0.042
|
PaO
2
24 h
| |||||
60 to 200 mmHg | 58.5 | 29.2 | 1.000 | ||
< 60 mmHg | 36.6 | 37.8 | 1.474 | 0.670 to 3.243 | 0.334 |
>200 mmHg | 4.9 | 0 | 0 | ||
PaCO
2
24 h
| |||||
30 to 50 mmHg | 76.9 | 24.1 | 1.000 | ||
<30 mmHg | 5.6 | 50 | 3.150 | 0.589 to 16.859 | 0.180 |
>50 mmHg | 17.6 | 52.6 | 3.500 | 1.248 to 9.819 |
0.017
|
CO
3
H 24 h
| |||||
20 to 26 mEq/L | 43 | 26.9 | 1.000 | ||
<20 mEq/L | 15.7 | 26.3 | 0.969 | 0..295 to 3.189 | 0.959 |
>26 mEq/L | 41.3 | 36 | 1.527 | 0.658 to 3.544 | 0.325 |
BE 24 h
| |||||
+4 to -4 | 50 | 19.6 | 1.000 | ||
<-4 | 23.2 | 38.5 | 2.557 | 0.914 to 7.155 | 0.774 |
> + 4 | 26.8 | 46.7 | 3.580 | 1.351 to 9.482 |
0.010
|
FiO
2
24 h
| |||||
<0.50 | 21.4 | 28 | 1.000 | ||
0.50 to 0.79 | 19.7 | 30.4 | 1.387 | 0.511 to 3.765 | 0.521 |
≥0.80 | 59 | 30.4 | 2.301 | 0.850 to 6.229 |
0.100
|
PaO
2
/FiO
2
24 h
| |||||
>300 | 21 | 13.6 | 1.000 | ||
200 to 300 | 17.1 | 22.2 | 3.128 | 0.974 to 10.049 | 0.056 |
<200 | 61.9 | 40 | 1.312 | 0.284 to 6.067 | 0.728 |
Lactic acid 24 h
| |||||
<2 mmol/L | 66.7 | 26.9 | 1.000 | ||
2 to 5 mmol/L | 20.5 | 31.2 | 1.234 | 0.364 to 4.187 | 0.736 |
>5 mmol/L | 12.8 | 40 | 1.810 | 0.444 to 7.380 | 0.408 |
Pre-arrest, resuscitation and post-ROSC factors
Mortality risk factors | Odds ratio | 95% CI | P -value |
---|---|---|---|
Hemato-oncologic illness | 2.633 | 1.072 to 6.469 | 0.035 |
Neurologic cause of cardiac arrest | 5.528 | 1.726 to 17.701 | 0.004 |
Place of arrest (emergency department) | 3.170 | 1.707 to 5.887 | <0.001 |
Inotropic drugs prior to cardiac arrest | 2.191 | 1.194 to 4.020 | 0.011 |
Sodium bicarbonate administration during resuscitation | 3.241 | 1.850 to 5.677 | <0.001 |
PaCO2 < 30 mmHg 1 h after ROSC | 2.623 | 1.076 to 6.397 | 0.034 |
PaCO2 > 50 mmHg 1 h after ROSC | 2.004 | 1.011 to 3.970 | 0.046 |
FiO2 ≥ 0.80 24 hours after ROSC | 4.611 | 1.934 to 10.993 | <0.001 |
Discussion
Oxygenation and ventilation parameters
Lactid acid
Vasoactive treatment
Pre-arrest, resuscitation and post-ROSC multivariate analysis
Limitations
Conclusions
Key messages
-
Secondary in-hospital mortality among the initial survivors of CA is high (43.5% in our study)
-
The most important early mortality risk factors after ROSC in-hospital CA in children were hyperventilation, hypoventilation, need for high doses of inotropic drugs, high lactic acid levels and high FiO2 requirements
-
High lactic acid levels at 1 hour after ROSC were associated with bad neurological outcomeEarly treatment of hemodynamic and respiratory disturbances after ROSC could improve mortality in initial survivors of CA