Measuring Invasive Blood Pressure during Pediatric In-Hospital Cardiac Arrest: PLS 4160.08 TF SR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (A Topjian is an author of Kienzle 2023)

CoSTR Citation

Gray JM, Christoff A, Nuthall G, Morrison LJ, Sahai A, Frazier M, Loeb D, Carlisle MA, Scholefield B, on behalf of the Pediatric Life Support Task Force. Measuring invasive blood pressure during pediatric in-hospital cardiac arrest: Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium, International Liaison Committee on Resuscitation (ILCOR) Pediatric Life Support Task Force, 2025, Available from http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of blood pressure targets during cardiac arrest (Gray 2024 – PROSPERO CRD42024590080), by clinical content experts of the Pediatric Life Support Task Forces of ILCOR, with assistance from Jessie Cunningham, Information Specialist at The Hospital for Sick Children, Toronto, Canada. Evidence was sought and considered by members of the Pediatric Life Support Task Force group.

Systematic Review

Gray et al, . Measuring invasive blood pressure during pediatric in-hospital cardiac arrest: a systematic review (in preparation)

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Infants and children receiving resuscitation after in-hospital cardiac arrest with intra-arterial blood pressure (IABP) monitoring in place at the time of arrest

Intervention: A specific blood pressure target during arrest

Comparators: A different blood pressure target or no blood pressure target

Outcomes: Return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with good neurological outcome were ranked as critical outcomes per Pediatric Core Outcome Set for Cardiac Arrest.¹

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as there is an English abstract

Timeframe: All years

PROSPERO Registration CRD42024590080

Consensus on Science

Five studies were included from the systematic review of the literature.^2-6 All five were observational cohort studies. Three were analyses of the same cohort (Pediatric Intensive Care quality of CPR study [PICqCPR]) but examined different sub-populations or different outcomes.^3,5,6

Diastolic blood pressure

For the critically important outcomes of return of spontaneous circulation (ROSC), survival to hospital discharge (SHD), and survival with favorable neurological outcome (FNO), we identified two observational studies enrolling 577 patients with in-hospital cardiac arrest (IHCA) and invasive arterial blood pressure monitoring in place at the time of arrest^2,3 (P), which showed benefit from exposure to diastolic blood pressure (DBP) of ≥25 mmHg for infants <1 and ≥30 mmHg for children ≥1 for the first 10 minutes of CPR (I) when compared with lower DBP (C) (RR of ROSC 1.33 [95% CI 1.12-1.59], see table 1).

For the critically important outcome of new substantive morbidity in survivors (defined as Functional Status Scale [FSS] increase of at least 3 points total or increase of 2 points in a single domain at the time of hospital discharge) (O), we identified very low-certainty evidence (downgraded for imprecision and indirectness) from a single study enrolling 77 subjects who survived IHCA with invasive blood pressure monitoring in place at the time of arrest⁵ (P), which showed no difference between exposure to a DBP of ≥25 mmHg for infants <1 and ≥30 mmHg for children ≥1 for the first 10 minutes of CPR (I) and a lower DBP (C) (adjusted RR 1.69 [95% CI 0.83-3.42]; 153 more patients/1,000 [95% CI 38 fewer to 538 more patients/1000]). Furthermore, there was no difference between median DBPs between subjects with new substantive morbidity and those without (30.5 mmHg vs 30.9 mmHg, p = 0.5). This was a sub-population of the subjects in Berg 2018.³ Relative risks are summarized in Table 1.

Table 1

Explanations

a. Two secondary analyses of prospective cohorts

b. Berg 2018 showed an improvement to FNO with the intervention, but Berg 2023 did not

c. Secondary analysis of a single cohort with 77 subjects included

Diastolic blood pressure – subgroups

For the critically important outcome of SHD (O), we identified very low certainty evidence (downgraded for imprecision and indirectness) from a single observational study enrolling children with an IHCA, invasive arterial blood pressure monitoring in place at the time of arrest, and either medical cardiac disease (n=24) or surgical cardiac disease (n=88) (P).⁶ Only patients with surgical cardiac disease had benefit from exposure to a DBP of ≥25 mmHg for infants <1 and ≥30 mmHg for children ≥1 for the first 10 minutes of CPR (I) when compared with patients with lower DBP (C) (Table 2). This was a sub-population of the subjects in Berg 2018.³

Table 2

Explanations

a. Secondary analysis of a multi center prospective cohort

Systolic blood pressure

For the critically important outcomes of SHD and survival with FNO (O), we identified very low-certainty evidence (downgraded for imprecision and indirectness) from two observational studies enrolling children with in-hospital cardiac arrest and invasive arterial blood pressure monitoring in place at the time of arrest^2,3 (P), which showed no difference from exposure to a systolic blood pressure (SBP) of ≥60 mmHg for infants <1 and ≥80 mmHg for children ≥1 for the first 10 minutes of CPR (I) when compared with lower SBP (C) (Table 3).

For the critically important outcome of new substantive morbidity in survivors (defined as Functional Status Scale [FSS] increase of at least 3 points total or increase of 2 points in a single domain at the time of hospital discharge) (O), we identified very low-certainty evidence (downgraded for imprecision and indirectness) from a single study enrolling 77 subjects who survived in-hospital cardiac arrest and invasive blood pressure monitoring in place at the time of arrest⁵ (P), which showed no difference from exposure to a SBP of ≥60 mmHg for infants <1 and ≥80 mmHg for children ≥1 for the first 10 minutes of CPR (I) compared to a lower SBP (C) (table 3). Furthermore, there was no difference between the median diastolic blood pressures between subjects with new substantive morbidity and those without (76.3 mmHg vs 63 mmHg, p = 0.2). This was a sub-population of the subjects in Berg 2018.³

Explanations

a. Two secondary analyses of prospective cohorts

b. Secondary analysis of a single cohort

c. Secondary analysis of a single cohort with 77 subjects included

Presence of monitoring

For the critically important outcomes of ROSC, SHD, survival with FNO (defined as pediatric cerebral performance category of 1-2 or no change from baseline) (O), we identified very low-certainty evidence (downgraded for imprecision and indirectness) from a single study which included 2886 subjects with IHCA and invasive blood pressure monitoring in place at the time of arrest⁴ (P), which showed no difference between the post-hoc report of clinician use of invasive blood pressure for monitoring of CPR quality (I) when compared to no use of monitoring (C) (table 4).

Table 4

Explanations

a. Single registry study

Treatment Recommendations

We suggest targeting an intra-arrest diastolic blood pressure of ≥25mmHg for infants <1 year and ≥30mmHg for children 1 to 18 years with invasive blood pressure monitoring in place at the time of in-hospital cardiac arrest (weak recommendation, very low certainty of evidence).

Justification and Evidence to Decision Framework Highlights

The Pediatric Life Support Task Force previously examined the evidence and made no recommendation regarding the use of intra-arrest blood pressure monitoring in pediatric cardiac arrest. A previous scoping review in 2020 did not find sufficient evidence to recommend a systematic review, but the publication of a new observational study in 2023 prompted the task force to undertake one.^2,7

Measurement of intra-arrest blood pressure is generally available only in high-resource settings, and all studies examined patients with invasive blood pressure monitoring in place at the time of arrest. While this limits the scope of the recommendation, children with invasive blood pressure monitoring may be at higher risk of suffering cardiac arrest, thus making a recommendation valuable.

No randomized controlled trials were identified in the search. We found only very-low-certainty evidence from five observational trials, all of which were from in-hospital cardiac arrest cohorts in the United States (ICU-RESUScitation⁸, Pediatric Intensive Care quality of CPR study³ [PICqCPR], and Get With the Guidelines-Resuscitation [GWTG-R]). Furthermore, Berg 2018, Yates 2019, and Wolfe 2019 all used the PICqCPR cohort, but with different sub-populations or outcome measures.^3,5,6

The task force noted that in Berg 2018, the same population was used to both generate and validate the cutoffs of 25mmHg and 30 mmHg for infants and children, respectively.³ Berg 2023 examined other cutoffs but found 25mmHg and 30 mmHg to be most predictive.² Additionally, we noted that while Berg 2018 showed a benefit in FNO (aRR 1.6 [95%CI 1.1-2.5]), Berg 2023 did not (aRR 1.14 [95% CI 0.93-1.39]). The pooled estimate suggested benefit (aRR 1.37 [95% CI 1.04-1.69]). Lastly, we noted that certain subgroups were under-represented, including children with heart disease and older children.

While the evidence is both indirect and imprecise, as described above, the task force limited the recommendation to children with invasive blood pressure monitoring in place at the time of in-hospital cardiac arrest.

Knowledge Gaps

• There are no interventional, randomized controlled trials comparing the benefits or harms of specific blood pressure targets during arrest
• There are no studies examining the use of non-invasive methods to measure blood pressure during arrest
• There are no studies examining whether different blood pressure targets would be more appropriate for older children or adolescents
• There are no studies examining the utility of initiating invasive blood pressure monitoring intra-arrest
• Children with heart disease are under-represented
• Studies focused primarily on blood pressures in the first 10 minutes of CPR; the importance of diastolic and systolic blood pressure in longer arrests is unknown
• No studies examined the effect of mean arterial pressure on outcomes

EtD: PLS 4160 08 IABP Monitoring Et D SAC approved

References

References listed alphabetically by first author last name in this citation format (Circulation)

1. Topjian AA, Scholefield BR, Pinto NP, Fink EL, Buysse CMP, Haywood K, Maconochie I, Nadkarni VM, de Caen A, Escalante-Kanashiro R, et al. P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation. 2020;142:e246-e261. doi: 10.1161/CIR.0000000000000911

2. Berg RA, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, et al. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med. 2023;51:91-102. doi: 10.1097/CCM.0000000000005715

3. Berg RA, Sutton RM, Reeder RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Meert KL, Yates AR, Harrison RE, et al. Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival. Circulation. 2018;137:1784-1795. doi: 10.1161/CIRCULATIONAHA.117.032270

4. Kienzle MF, Morgan RW, Alvey JS, Reeder R, Berg RA, Nadkarni V, Topjian AA, Lasa JJ, Raymond TT, Sutton RM, et al. Clinician-reported physiologic monitoring of cardiopulmonary resuscitation quality during pediatric in-hospital cardiac arrest: A propensity-weighted cohort study. Resuscitation. 2023;188:109807. doi: 10.1016/j.resuscitation.2023.109807

5. Wolfe HA, Sutton RM, Reeder RW, Meert KL, Pollack MM, Yates AR, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, et al. Functional outcomes among survivors of pediatric in-hospital cardiac arrest are associated with baseline neurologic and functional status, but not with diastolic blood pressure during CPR. Resuscitation. 2019;143:57-65. doi: 10.1016/j.resuscitation.2019.08.006

6. Yates AR, Sutton RM, Reeder RW, Meert KL, Berger JT, Fernandez R, Wessel D, Newth CJ, Carcillo JA, McQuillen PS, et al. Survival and Cardiopulmonary Resuscitation Hemodynamics Following Cardiac Arrest in Children With Surgical Compared to Medical Heart Disease. Pediatr Crit Care Med. 2019;20:1126-1136. doi: 10.1097/PCC.0000000000002088

7. Kool M, Atkins DL, Van de Voorde P, Maconochie IK, Scholefield BR, Force PIT. Focused echocardiography, end-tidal carbon dioxide, arterial blood pressure or near-infrared spectroscopy monitoring during paediatric cardiopulmonary resuscitation: A scoping review. Resusc Plus. 2021;6:100109. doi: 10.1016/j.resplu.2021.100109

8. Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, et al. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA. 2022;327:934-945. doi: 10.1001/jama.2022.1738