Chun et al. BMC Pediatrics(2024) 24:563
https://doi.org/10.1186/s12887-024-05037-x

BMC Pediatrics

RESEARCH

Open Access

The association between initial postresuscitation diastolic blood pressure
and survival after pediatric cardiac arrest:
a retrospective study
Min Kyo Chun1†, Jun Sung Park1†, Jeeho Han1†, Won Kyoung Jhang1† and Da Hyun Kim1*†
Abstract
Background Limited research has analyzed the association between diastolic blood pressure (DBP) and survival after
pediatric cardiopulmonary resuscitation (CPR). This study aimed to explore the association between post-resuscitation
diastolic blood pressure and survival in pediatric patients who underwent CPR.
Method This retrospective single-center study included pediatric patients admitted to the pediatric intensive careunit of Asan Medical Center between January 2016 to November 2022. Patients undergoing extracorporeal CPR andthose with unavailable data were excluded. The primary endpoint was survival to ICU discharge.
Results A total of 106 patients were included, with 67 (63.2%) achieving survival to ICU discharge. Multivariate
logistic regression analysis identified DBP within 1 h after ROSC as the sole significant variable (p = 0.002, aOR, 1.043;
95% CI, 1.016–1.070). Additionally, DBP within 1 h demonstrated an area under the ROC curve of 0.7 (0.592–0.809) for
survival to ICU discharge, along with mean blood pressure within the same timeframe.
Conclusion Our study highlights the importance of DBP within 1-hour post-ROSC as a significant prognostic factor
for survival to ICU discharge. However, further validation through further prospective large-scale studies is warranted
to confirm the appropriate post-resuscitation DBP of pediatric patients.
Keywords Diastolic blood pressure, Cardiopulmonary resuscitation, Survival rate, Post-resuscitation†

Min Kyo Chun and Da Hyun Kim contributed equally to this work.

†

Jun Sung Park, Jeeho Han and Won Kyoung Jhang contributed
equally to this work.
*Correspondence:
Da Hyun Kim
gdahyeon59@gmail.com
1
Department of Pediatrics, Asan Medical Center, University of Ulsan
College of Medicine, Seoul, Republic of Korea

IntroductionMore than 300,000 pediatric patients experience out-ofhospital cardiac arrest (OHCA) or in-hospital cardiac
arrest (IHCA) in the United States alone [1, 2]. However,despite improvements in post-cardiopulmonary resuscitation (CPR) over recent decades, there is a persistenthigh morbidity, accompanied by a mortality rate exceeding 65% [2, 3].
The lower limit of cerebral autoregulation should be
adjusted higher for post-resuscitation patients. Theoretically, higher blood pressure can achieve better cerebral
blood perfusion, which can lead to improved neurologic© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Chun et al. BMC Pediatrics(2024) 24:563

outcomes [4, 5]. A previous study reported that analysesof systolic blood pressure (SBP) and mean blood pressure (MBP) after CPR contributed to improving neurological outcomes or survival by high levels of SBP and
MBP [6–11]. Some recent studies in adults have emphasized diastolic blood pressure (DBP) for better outcomes,
with similar findings also observed in children [12–14].
In a recent prospective observational multicenter study
for pediatric patients with IHCA, maintaining DBP 25
mmHg or higher in infants and 30 mmHg or higher inchildren over the age of 1 during the first 10 min of CPR
was associated with survival to hospital discharge andfavorable neurologic outcomes [12].
However, most published studies have measured DBP
during CPR using an invasive arterial catheter. Moreover, most of the studies that analyzed DBP in post-CPR
were conducted on adults and the number of studies was
small.
We therefore aimed to investigate the relationshipbetween post-resuscitation DBP and mortality in patients
who underwent CPR. We hypothesized that a higher
DBP after CPR would lead to lower mortality.

Methods
Study population

This was a single-center retrospective observational
study. The study population was extracted from the
medical records of all pediatric patients who experienced resuscitated cardiac arrest and were admitted to
the 14-bed multidisciplinary pediatric intensive careunit (PICU) at Asan Medical Center, a tertiary academic
referral hospital in Seoul, south Korea. The Institutional
Review Board of the University of Ulsan College of Medicine reviewed and approved this study (No.2024-0033)
and waived the need for parental consent given the retrospective nature of the study. We had access to information that could identify individual participants byelectrical medical records between 8. Jan. 2024 and 25.
Jan. 2024.
Both pediatric survivors of OHCA and IHCA from January 2016 to November 2022 were included in the study.
These patients were managed in accordance with the current guidelines for pediatric basic and advanced life support [15]. Patients with insufficient data or who received
ECMO support during resuscitation were excluded given
the potential influence of extracorporeal circulation on
hemodynamic monitoring.
Data collection

The demographics, underlying diseases, etiology of cardiac arrest, characteristics of cardiac arrest (bystander
CPR, initial rhythm, duration of CPR, pharmacologic
intervention), baseline Pediatric Cerebral Performance
Category (PCPC) score, and baseline vasoactive inotropic

Page 2 of 8score (VIS) of all patients were obtained. After the returnof spontaneous circulation (ROSC), initial and worst
blood pressure (systolic blood pressure, diastolic bloodpressure, mean blood pressure) within 1 h were analyzed.
The worst VIS within 24 h, ICU length of stay, use of
CRRT or ventilator, and neurologic outcome calculated
through PCPC score at ICU discharge were also assessed.
PCPC 1 was defined as alert mentality with good cerebral performance, PCPC 2 as conscious, but with thepossibility of mild neurologic deficit; PCPC 3 as conscious with cerebral disability; PCPC 4 as conscious with
impaired brain function; PCPC 5 as coma or vegetative
state; PCPC 6 as brain death or dead. Patients who werecomatose after ROSC were managed with therapeutic
hypothermia, performed with Blanketroll III (Genteherm
Medical, Cincinnati, OH, USA) with the target temperature (34–35℃) maintained for 48 h. Patients witharrhythmia or lactic acidosis with poor circulation during therapeutic hypothermia were managed with a target
temperature of 36℃. Hemodynamic status was recorded
by non-invasive blood pressure (NIBP) monitoring in theemergency room (ER) or general ward. Mean blood pressure (MBP) was estimated using the following formula:
MBP = DBP + 1/3 (SBP–DBP). When measuring bloodpressure, it can be elevated if the child is crying or restless, so we measured blood pressure after the child had
calmed down, usually during feeding or sleep. The bloodpressure cuff size was chosen according to the following
criteria: the cuff length was 40% of the distance from theelbow to the shoulder, and the width was approximately
40% of the arm circumference, measured at the midpoint
between the olecranon and acromion. If the blood pressure reading was outside the normal range for the child’sage, measurements were repeated up to three times consecutively, and the final reading was recorded.
Initial blood pressure was defined as NIBP measured
for the first time after ROSC. Then, we follow the bloodpressure every 5 min and recorded the worst value within
1 h after recovery. The primary endpoint of this study
was survival to ICU discharge.
Statistical analysis

The categorical variables or outcomes of enrolled
patients were summarized using frequencies and percentages and were analyzed using the chi-squared test or
two-tailed Fisher’s exact test, as appropriate. Continuous
data were expressed as mean ± standard deviation (SD)or median with interquartile range (IQR) and comparedusing a two-tailed Student’s t-test. Measured blood pressure after ROSC with p-values of < 0.05 was included ina stepwise logistic regression for predicting independent variables by reporting an odds ratio (OR) with 95%
confidence intervals (CI). To evaluate the discriminative
ability of DBP, we analyzed initial blood pressure andChun et al. BMC Pediatrics(2024) 24:563

the worst blood pressure within 1 h after ROSC using
receiver operating characteristic (ROC) curves with thecorresponding area under the curve (AUC) and relatedsensitivity and specificity. All p-values of < 0.05 were considered to be statistically significant. All data were analyzed using IBM SPSS Statistics for Windows, version
21.0 (IBM Corp, Armonk, NY, USA).

Fig. 1 Flow diagram of patients included in analysis

Page 3 of 8

Results
A total of 238 pediatric survivors of CPR, of which 106
were finally enrolled. Among the screened patients,
patients not achieve ROSC (n = 76), patients who underwent extracorporeal CPR (n = 18), under 1 month orabove 18 years (n = 15), or had insufficient data (n = 23)
were excluded. Finally, a total of 67 patients (63.2%) were
included in the survival of ICU discharge group and 39(36.8%) were included in the non-survival of ICU discharge group (Fig. 1.)

Chun et al. BMC Pediatrics(2024) 24:563

Page 4 of 8

The demographic and clinical characteristics are summarized in Table 1. No differences in age, sex, bodyweight, or ICU length of stay were noted between the twogroups. The most common underlying disease in bothgroups was cardiac disease. Respiratory decompensation
was the most common cause of cardiac arrest across thetwo groups; however, a greater proportion of cardiogenic
and hypovolemic shock was observed in non-survivors

compared to survivors. With the exception of pharmacological intervention, there were no statistically significant differences observed in the variables related to
cardiac arrest between the two groups. After ROSC, allblood pressure, including the worst value within 1 h wassignificantly higher in the survival group than in the nonsurvival group.

Table 1 The demographic and characteristics of study patients
Variables

Total(N = 106)Survival to
ICU discharge (N = 67)

Age (mo), median (IQR)

22.13(4.5-78.57)
68 (64.2)
13.2 ± 13.3
39.4 ± 66.9

16.5
(3.67–75.92)
45 (67.2)
12 ± 11.41
38.6 ± 61.87

Non survival to
ICU discharge(N = 39)30.3(8.07–99.63)
23 (59)15.18 ± 16.03
40.72 ± 75.65

6 (5.7)35 (33)17 (16)23 (21.7)
3 (2.8)4 (3.8)4 (3.8)1 (0.9)13 (12.3)

3 (4.5)22 (32.8)
11 (16.4)
14 (20.9)
2 (3)
4 (6)
1 (1.5)0
10 (14.9)

3 (7.7)13 (33.3)
6 (15.4)
9 (23.1)
1 (2.6)0
3 (7.7)
1 (2.6)3 (7.7)71 (67)25 (23.6)
10 (9.4)

52 (77.6)
13 (19.4)
2 (3)

19 (48.7)
12 (30.8)8 (20.5)

92 (86.8)
14 (13.2)
104 (98.1)

60 (89.6)
7 (10.4)
67 (100)

32 (82.1)
7 (17.9)37 (94.9)

98 (92.4)
7 (6.6)13.7 ± 19

61 (91.1)6 (9)12.7 ± 21

38 (97.4)
1 (2.6)15.41 ± 14.96

0.442

68 (64.2)
30 (28.3)
20 (18.9)
2.2 ± 1.1
13.5 ± 36.9

32 (47.8)
13 (19.4)
8 (11.9)
2.18 ± 1.14
4.13 ± 20.38

36 (92.3)
17 (43.6)
12 (30.8)
2.21 ± 1.03
29.53 ± 51.18< 0.001
0.013
0.002
0.914
< 0.00194.74 ± 24.78
55.48 ± 18.63
68.6 ± 19.39
89.27 ± 24.42
53.87 ± 19.03
65.64 ± 19.94

98.99 ± 25.27
58.69 ± 18.04
72.09 ± 19.15
95.37 ± 23.22
58.6 ± 17.78
70.85 ± 18.39

87.39 ± 22.02
49.97 ± 18.56
62.62 ± 18.53
79.10 ± 23.2
45.97 ± 18.64
56.97 ± 19.60

0.015
0.021
0.014
0.001
0.001
0.001

Gender, male
Body weight (kg)ICU length of stay (d)Underlying disease
None
Cardiac disease
Respiratory disease
Hemato-malignancy
Gastrointestinal disease
Neuromuscular disease
Epilepsy
Renal disease
Metabolic disease
Etiology of cardiac arrest
Asphyxia/respiratory failure
Cardiogenic shock
Hypovolemic shock
Characteristics of cardiac arrest
CPR arrest location
In-hospital cardiac arrest
Out-of hospital cardiac arrest
Bystander CPR
Initial rhythm
Asystole/PEA
VT/VF
CPR duration (min)Pharmacologic intervention
Epinephrine
Sodium bicarbonate
Calcium gluconate
Baseline PCPC score
Baseline vasoactive inotropic score
After ROSC
Initial systolic blood pressure
Initial diastolic blood pressure
Initial mean blood pressure
Systolic blood pressure within 1 h
Diastolic blood pressure within 1 h
Mean blood pressure within 1 h

P-value

0.299
0.409
0.280
0.882
0.419

0.002

0.373

0.133
0.378

Abbreviation ICU = intensive care unit; CPR = cardiopulmonary resuscitation; PEA = pulseless electrical activity; VT = ventricular tachycardia; VF = ventricular fibrillation;
PCPC = pediatric cerebral performance category; ROSC = return of spontaneous circulation

Chun et al. BMC Pediatrics(2024) 24:563

Page 5 of 8

Table 2 Comparison of outcomes between survival and nonsurvival patients
Variables

PCPC score
Vasoactive Inotropic drugscore within 24 h
Duration of vasoactive drug
Duration of ventilator
Use of CRRT n, (%)

Survival to
Non surICU discharge vival to ICU
discharge
2.55 ± 1.41
5.74 ± 0.72
19.72 ± 32.71
94.71 ± 75.07

Pvalue5.84 ± 10.98
32.12 ± 69.39
3 (4.4)< 0.001
0.566
0.017

36.51 ± 75.7
40.46 ± 76.06
8 (20.5)< 0.001< 0.001

Abbreviation ICU = intensive care unit; PCPC = pediatric cerebral performance
category; CRRT = continuous replacement renal therapy

Table 3 Related factors for the survival: Univariate andmultivariate logistic regression analysis
Variables

Univariate
p-value
OR (95% CI)

Age

0.295

Initial systolic bloodpressure
Initial diastolicblood pressure
Initial mean bloodpressure
Systolic blood pressure within 1 h
Diastolic blood pressure within 1 h

0.022

Mean blood pressure within 1 h

0.001

0.023
0.018
0.002
0.002

Multivariate
p-value
Adjusted OR
(95%
CI)

0.997
(0.993–1.002)
1.032(1.012–1.053)
1.028(1.004–1.053)
1.028(1.005–1.052)
1.032(1.012–1.053)
1.043
0.002
(1.016–1.070)

1.043(1.016–1.070)

1.043(1.017–1.069)

Abbreviation OR = odds ratio; CI = confidence interval

Vasoactive inotropic drug score within 24 h and duration of using the vasoactive drug were higher in the nonsurvival group. However, the duration of the ventilator
did not significantly differ (Table 2).
Based on the t-test analysis in Table 1, the univariate logistic regression analysis also revealed statisticallysignificant differences across all blood pressure values.
However, the results of the multivariate logistic regression analysis revealed that DBP within the first hour
was a significant variable (p = 0.002, aOR, 1.043; 95% CI,
1.016–1.070) (Table 3).
Additionally, DBP within the first hour demonstrated
an area under the ROC curve (AUROC) of 0.7 (0.592–
0.809) for predicting survival to ICU discharge (Fig. 2).
The cut point of the area under the curve and related sensitivity and specificity for SBP, DBP, and DBP within thefirst hour were 93, 60, and 48, respectively.

Discussion
In this study, during the initial post-ROSC hour, our findings indicate that diastolic blood pressure had the mostinfluence on survival to ICU discharge following resuscitation. Despite MBP exhibiting a higher AUC value than
DBP, with marginal differences in significance, our multivariate logistic regression analysis established DBP as theindependent prognostic factor.
Numerous studies have explored the hemodynamic significance of DBP as a predictor of survival and favorable
neurologic outcomes during CPR [16–18]. Additionally,
many studies continue to identify various factors withhemodynamically significant implications in post-cardiac arrest. Our study has statistically demonstrated thatwithin the first hour post-resuscitation, DBP can serve as
an independent prognostic factor for survival to ICU discharge, in line with the findings of a recent adult study[19, 20]. With a greater influence than other blood pressure variables, DBP is a strong prognostic factor owing
to its effects on peripheral vascular tone and coronary
perfusion, whereas SBP has only a sensitive effect on cardiac contractility and volume change [21–23]. Relying
solely on SBP targets in post-resuscitation management
may effectively address circulatory shock, but there is anincurred risk of ischemic injury of the heart or end-organ
damage, ultimately increasing morbidity and mortality.
Maintaining an adequate DBP is crucial to reduce themortality risk associated with post-cardiac arrest syndrome, which induces systemic ischemia and reperfusion
injury by decreasing peripheral vascular tone [24–26].
Accordingly, our study revealed an association between
DBP during the early post-resuscitation stage and the riskof mortality at ICU discharge.
In addition to DBP, MBP demonstrated a positive
correlation with survival to ICU discharge in our study(Fig. 2). Previous studies have suggested that maintaining higher MBP levels is associated with improved outcomes. This observation can be ascribed to the pivotal
role of DBP in the calculation of MBP compared with
SBP. Consequently, given that raising and sustaining DBP
ultimately increases MBP, we posit that DBP may be considered the more essential factor.
Our study can be distinguished from previous studies
in several key ways. First, our study analyzed the lowest value within the first hour after ROSC, whereas previous studies evaluated the first NIBP or a mean value
within 6 h post-ROSC. Given the importance of avoiding interference from inotropic agent effects and TTM
in maintaining blood pressure during the first day after
cardiac arrest, we contend that our study helped minimize the error range through consideration of the NIBP
measurement.
Another differentiating factor is that the mean value ofthe worst DBP value within 1 h of enrollment exceededChun et al. BMC Pediatrics(2024) 24:563

Page 6 of 8

Fig. 2 Receiver operating characteristic (ROC) curve showing the initial blood pressure and the first hour after ROSC

45 mmHg for most patients. This implies that, despitesetting the cut-off value higher than the target DBP, ourstatistical analysis confirmed the significant influence of
DBP on survival to ICU discharge. This correlation aligns
with earlier studies, wherein setting the cut-off value ofthe lowest DBP as the 50th percentile for age-predictedsurvival and favorable neurologic outcomes for pediatricpost-cardiac arrest patients. Post-ROSC diastolic hypertension was also associated with survival to discharge[20, 27].
Studies evaluating the efficacy of DBP during CPR havetraditionally utilized invasive arterial catheters to monitor blood pressure. While invasive arterial catheters offer
superior accuracy compared with NIBP measurements, aprevious propensity-matched cohort study confirmed noassociation between the use of arterial catheters in critically ill patients with mechanical ventilators and hospitalmortality [28]. In the pediatric population, particularly ininfants, the technical challenges associated with inserting arterial catheters during CPR, coupled with the difficulties of performing this procedure in children withcomprised vascular perfusion even after ROSC, pose
substantial hurdles. Therefore, NIBP a more commonly
employed clinical tool in pediatric medicine, can serve asa practical device for monitoring blood pressure insteadof an arterial catheter. Despite a slightly lower accuracy,
our study holds clinical significance in drawing conclusions that are more widely applicable.

Chun et al. BMC Pediatrics(2024) 24:563

Page 7 of 8

Another distinguishing factor is that the primary outcome was survival to ICU discharge rather than survival
to hospital discharge. Given the relatively extended average ICU stay of over 30 days, which is notably longer
compared with other studies, we designated survival to
ICU discharge as the primary outcome.
This study has several potential limitations. First,
this study was a retrospective single-center study that
included a relatively small number of pediatric patients
who performed CPR compared with studies for adults.
Due to the limited patient pool, and despite age-related
variations in normal ranges, only simple values werecompared without detailed subgroup analyses. While
our study statistically established the influence of DBP
on post-cardiac arrest mortality, large-scale prospective
studies specifically focusing on pediatric patients are warranted to accurately determine the effectiveness of DBP.
Second, certain prognostic factors, including inflammatory biomarkers reflecting neurological prognosis, lactate
levels, and initial blood gas analysis, electroencephalographic findings, and echocardiography findings were notconsidered in the assessment of mortality. Third, a previous study included only pediatric patients who underwent IHCA, whereas this study included both IHCA and
OHCA patients. Despite the relatively small proportionof OHCA cases (Table 1), the statistical insignificancebetween the two groups should be acknowledged.
In conclusion, within the initial hour post-ROSC, DBP
emerged as the blood pressure parameter exerting themost influence on survival to ICU discharge after resuscitation. Further prospective and large-scale studies are
warranted to validate the optimal DBP for post-resuscitation for pediatric patients.

ultimately translating to improved outcomes in this vulnerable population.

Conclusion
This study identified diastolic blood pressure (DBP)
within one-hour post-ROSC as the most significant
hemodynamic determinant of survival to intensive careunit discharge among resuscitated pediatric patients.
Multivariate analysis pinpointed DBP as the sole independent predictor, highlighting its prognostic relevance.
The area under the receiver operating characteristic
curve further substantiated DBP’s discriminative ability,
comparable to mean arterial pressure.
These findings underscore the pivotal role of DBP in
mitigating mortality risk associated with post-cardiac
arrest syndrome. By modulating peripheral vascular
resistance and coronary perfusion, optimizing DBP may
attenuate systemic ischemia-reperfusion injury more
effectively than targeting systolic pressures alone.
Nonetheless, prospective large-scale investigations are
warranted to establish evidence based DBP thresholds
specific to pediatric post resuscitation care. Such efforts
could refine hemodynamic management protocols,

Consent for publication
Not applicable.

Abbreviations
CPR	Cardiopulmonary Resuscitation
CRRT	Continuous Renal Replacement Therapy
DBP	Diastolic Blood Pressure
ECMO	Extracorporeal Membrane Oxygenation
ICU	Intensive Care Unit
IHCA	In-hospital Cardiac Arrest
MBP	Mean Blood Pressure
NIBP	Non-invasive Blood Pressure
OHCA	Out-of-hospital Cardiac Arrest
PCPC	Pediatric Cerebral Performance Category
ROSC	Return of Spontaneous Circulation
SBP	Systolic Blood Pressure
TTM	Target Temperature Management
VIS	Vasoactive Inotropic Score
Acknowledgements
Not applicable.
Author contributions
MK.C and DH.K conceptualized the design of the study, contributed to thestatical analysis and interpretation of the data, drafted the initial manuscript.
JS.P, reviewed the initial and the revised draft of the manuscript. JH.H
contributed the acquisition of the data. WK.J coordinated and supervised datacollection. All authors read, provided feedback, and approved the final versionof this article. All authors reviewed the manuscript.
Funding
This study was not supported by any funding or grants.
Data availability
The dataset analyzed during this study are available from the corresponding
author on reasonable request.

Declarations
Ethics approval and consent to participate
This study was approved by the Asan Medical Center Ethics Committee,
University of Ulsan College of Medicine (2024-0033) and waved the need forparental consent given the retrospective nature of the study.

Competing interests
The authors declare no competing interests.
Received: 11 April 2024 / Accepted: 27 August 2024

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