Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study
Authors: Gardner Monique M. , Hehir David A. , Reeder Ron W. , Ahmed Tageldin , Bell Michael J. , Berg Robert A. , Bishop Robert , Bochkoris Matthew , Burns Candice , Carcillo Joseph A. , Carpenter Todd C. , Dean J. Michael , Diddle J. Wesley , Federman Myke , Fernandez Richard , Fink Ericka L. , Franzon Deborah , Frazier Aisha H. , Friess Stuart H. , Graham Kathryn , Hall Mark , Harding Monica L. , Horvat Christopher M. , Huard Leanna L. , Maa Tensing , Manga Arushi , McQuillen Patrick S. , Meert Kathleen L. , Morgan Ryan W. , Mourani Peter M. , Nadkarni Vinay M. , Naim Maryam Y. , Notterman Daniel , Pollack Murray M. , Sapru Anil , Schneiter Carleen , Sharron Matthew P. , Srivastava Neeraj , Tilford Bradley , Viteri Shirley , Wessel David , Wolfe Heather A. , Yates Andrew R. , Zuppa Athena F. , Sutton Robert M. , Topjian Alexis A. 
Published: October 2023

Abstract
Introduction
Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge.

Methods
We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1–3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes.

Results
Among 693 index events with 0–6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001).

Conclusions
Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.