Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study*

Abstract

Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort.

Testing Physiologic Endpoint-Directed Cardiopulmonary Resuscitation: Precision Cardiopulmonary Resuscitation on the Horizon*

“…These intra-arrest diastolic pressure thresholds were selected based on preliminary information generated from a single-center study that showed promising improvement in survival on hospital discharge and in survival with favorable neurologic outcome in 164 participants. Differently, in the current study by Berg et al (1), after adjusting for age, initial rhythm, location (PICU or cardiac ICU [CICU]), and institution, the investigators found an increased rate of survival to hospital discharge and rate of return of circulation, but the risk of survival with favorable neurologic outcome was not different in patients in who the diastolic physiologic endpoints were attained. Disappointed, the investigators speculate that the difference in conclusion between the two studies may be explained by some differences in sample characteristics between the single and multicenter trial and a possible ceiling effect reached in some subgroups.…”

“…In this issue of Critical Care Medicine , in a study authored by Berg et al (1), the investigators tried to answer an important question for clinicians delivering cardiopulmonary resuscitation (CPR) in children: is attaining a diastolic arterial pressure during CPR helpful? They tested the hypothesis that using diastolic pressure-directed intra-arrest resuscitation measures would improve survival.…”

“…There is no information analyzed on the postcardiac arrest phases of care in the study by Berg et al (1), and several factors that may contribute to the neurologic outcome during the reperfusion phase were not evaluated (e.g., magnitude or duration of hypotension) (12). Additionally, the great majority of the sample of the current study by Berg et al (1) was composed of children less than 1 year old, surgical cardiac patients, and children with congenital heart disease. Although the investigators adjusted their estimates for age and for location (PICU or CICU), the biological impact of these variables may have been incompletely accounted with the statistical adjustment.…”

“…Although the investigators adjusted their estimates for age and for location (PICU or CICU), the biological impact of these variables may have been incompletely accounted with the statistical adjustment. The brain's developmental age, the type of congenital heart disease, and the status of the brain post cardiopulmonary bypass may each have different effects on the neurologic outcome (either favorable or unfavorable); the study by Berg et al (1) was not suited to deconstruct these adequately. Furthermore, the functional outcome on hospital discharge measured with the categorical scales selected may have not been sufficient to detected meaningful neurologic change in the study by Berg et al (1) with such a large infant group less than 1 year old.…”

“…The results of the study by Berg et al (1) are nevertheless very important for the field of pediatric resuscitation for several reasons. First, the study shows that in addition to the implementation and evaluation of a training and debriefing intervention across a large representative sample of institutions, physiologic recordings were possible, and these could be merged for analysis.…”