Abstract
Introduction
Pediatric in-hospital cardiac arrest (IHCA) is associated with high morbidity and mortality, yet factors influencing survival are incompletely understood. The aim of the study is to evaluate factors affecting immediate and short-term survival in IHCA, focusing on cardiopulmonary resuscitation (CPR) duration, initial rhythm, and arrest location.
Methods
This retrospective cohort study included 365 patients aged 1 day to 14 years with IHCA who presented at the King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia between 2013 and 2022. Key resuscitation variables such as CPR duration, initial rhythm, and arrest site were analyzed. The primary outcomes were the return of spontaneous circulation (ROSC) and 28-day survival. Demographic and clinical data, including comorbidities and post-ROSC organ failure, were recorded. Multivariate logistic regression identified independent survival predictors.
Results
The 28-day survival rate was 25.2%. Longer CPR duration was linked to reduced ROSC and 28-day survival [odds ratio (OR)=1.11 per minute; p<0.001]. Median CPR duration was 7 minutes for ROSC compared to when ROSC was not achieved, which was 27 minutes (p<0.001). CPR lasting more than 15 minutes was likely to result in no ROSC, with a strong prediction accuracy of 82%, meaning it correctly identified cases 82% of the time, (p<0.001). IHCA in the emergency department (ED) was associated with ROSC failure (OR=4.12; p=0.006). Initial bradycardia was associated with better survival than asystole or pulseless electrical activity (p=0.031). There was no significant association between CPR duration and post-ROSC organ failure (p>0.05).
Conclusion
CPR duration, initial rhythm, and arrest location significantly influence immediate and 28-day survival in pediatric IHCA. These findings support the need for optimized, rhythm-specific resuscitation strategies, particularly for ED arrests requiring prolonged CPR. Future research should investigate strategies to reduce CPR duration and enhance survival.
Introduction
Pediatric in-hospital cardiac arrest (IHCA) is a critical condition that requires prompt professional management to enhance survival rates.1-3 Although infrequent, IHCA is linked to considerable morbidity and mortality.4, 5 High-quality cardiopulmonary resuscitation (CPR) is defined as chest compressions with sufficient depth (≥4 cm in infants and ≥5 cm in children), rate (100-120 compressions/min), minimal pauses, complete chest recoil, and adequate ventilation, according to American Heart Association (AHA) Guidelines.6 The quality and timing of CPR, initial cardiac rhythm, and the location of the arrest are certain factors that affect patients’ survival.7, 8 According to AHA Guidelines, high-quality CPR is characterized by proper compression depth, rate, and minimal interruptions that significantly improve survival outcomes.9 Bradycardia shows better outcomes than other initial rhythms, such as asystole and pulseless electrical activity (PEA), given that interventions remain timely and efficient.8, 10-15
Adult cardiac arrests have been extensively studied in the literature, particularly regarding the effects of initial rhythm, CPR duration, and arrest location-whether out-of-hospital, in the emergency department (ED), or within specialized units. Several studies have shown that arrests occurring in specialized units, such as the pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU), are associated with better outcomes.16-19 Given the importance of effective resuscitation and post-resuscitation efforts, alongside the absence of agreement on CPR duration effects and cut-off limits in terms of outcomes, further research is warranted.8, 20, 21 Therefore, this research aims to evaluate the effect of CPR duration, initial presenting cardiac rhythm, and arrest location on survival outcomes in pediatric IHCA. In addition, it seeks to identify predictors and factors that influence improved IHCA survival rates. By examining whether prolonged resuscitation is beneficial or detrimental, this study bridges a gap in clinical literature. The findings will provide evidence-based insights for medical stakeholders to inform CPR guidelines, support long-term improvement of pediatric IHCA outcomes, and enhance post-resuscitation care strategies.
Materials and Methods
Study Design and Population
The study adopted a retrospective design, analyzing data from 365 pediatric patients who experienced IHCA at King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia, and received CPR by pediatric advanced life support-certified teams. Patients were aged 1 day to 14 years, and data were collected at our center between January 2013 and December 2022. Those who experienced out-of-hospital cardiac arrest or required extracorporeal CPR following return of spontaneous circulation (ROSC) were excluded to maintain focus. Although the overall sample was substantial, subgroup analyses-particularly comparisons across arrest types-were limited by statistical power. All CPR interventions adhered to the latest AHA Guidelines, sustaining a compression rate of 100-120 per minute, achieving adequate depth, allowing full chest recoil, and minimizing interruptions.22
Ethical Considerations
The Institutional Review Board approved the study protocol at King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia (approval number: IRB 2032-82, date: 21.07.2023). Informed consent was waived for this research due to the retrospective nature of the studies. The study strictly adhered to institutional and national data-protection policies before data collection. To ensure confidentiality, all medical records were de-identified prior to analysis and access was restricted solely to authorized investigators. This research also complied with institutional rules and national guidelines for the use of patient records in retrospective studies.
Data Collection
Data were collected from participants’ medical records, including demographic information (age, gender, and postnatal history), clinical characteristics, reasons for hospital admission, and indications for NICU or PICU care. We also recorded details of each cardiac arrest: type, cause, and location (operating room, ED, inpatient ward, NICU, or PICU), as well as the electrocardiography rhythm at arrest [bradycardia, asystole, PEA, or pulseless ventricular tachycardia/fibrillation (VT/VF)]. Resuscitation details were reviewed, including CPR duration (time from collapse to ROSC or death), medications administered, procedures performed, and outcomes. Finally, we assessed achievement of ROSC, mortality, 28-day survival, and incidence of new organ failure following ROSC.
Study Outcomes
The primary outcome was ROSC, defined as the return of a palpable pulse with sustained circulation for at least 20 minutes. Secondary outcomes included survival to hospital discharge and survival rates at 28 days; identification of common factors leading to hospital or PICU admission that precipitated cardiac arrest; survival stratified by initial cardiac rhythm; and the incidence of new organ failure post-ROSC, along with its impact on survival.
Definitions
The cardiac arrest phase is defined as the duration from the cardiac arrest onset to the initiation of effective CPR. Therefore, prompt identification of worsening conditions by rapid response teams is essential for effective intervention.23, 24 CPR is defined as the administration of chest compressions and assisted ventilation in response to cardiac arrest or significant bradycardia accompanied by inadequate perfusion.25 The post-resuscitation phase is defined as the critical period after ROSC, necessitating rigorous monitoring for complications, including multi-organ failure and other adverse outcomes. Multi-organ failure is defined as the dysfunction of two or more organ systems, resulting in an inability to maintain spontaneous activity.
Statistical Analysis
The data analysis of the current research was performed using SPSS version 26.0 (IBM Corp., Armonk, NY). Normality evaluations of continuous variables were conducted through the Shapiro-Wilk test, and these variables were reported as the median and interquartile range (IQR), while categorical data were presented as frequencies and percentages. Comparative analyses were performed through the Mann-Whitney U test to compare CPR duration between two groups, whereas the Kruskal-Wallis test facilitated comparisons between more groups. Pairwise comparisons were conducted using the Bonferroni correction, and chi-square and Fisher’s exact tests were employed to compare proportions across categorical groups. Furthermore, receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic capability of CPR duration in predicting ROSC achievement/non-achievement. In multivariate logistic regression, variables significant in bivariate analysis (p<0.05) were included in the models to determine independent predictors of ROSC achievement and 28-day survival. All subsequent tests were conducted at a p<0.05 significance level.
Results
Demographic and Clinical Characteristics
The research included 365 pediatric patients who experienced IHCA between 2013 and 2022. The median age of the patients was 6 months (IQR: 1 to 36 months), with 55.1% of the population being male. In accordance with participant demographics, age and gender did not correlate with ROSC achievement.
Location of First Cardiac Arrest
Patients with arrests in the emergency room (ER) showed significantly lower ROSC rates (p=0.001) compared to patients whose arrests occurred in PICUs, NICUs, wards, or operating rooms, as shown in Table 1. This may be related to the nature of most ER settings, which affect the resuscitation process as they are often over-stressed and resource limited.
Rhythm at the Time of Arrest
Cardiac rhythm, at the time of arrest, showed a stronger association with ROSC outcomes. Most patients with bradycardia showed poor perfusion (69%), followed by asystole (16.7%), PEA (10.1%), and pulseless VT/VF (4.1%). Patients with bradycardia showed better outcomes (p=0.031) in comparison to patients with asystole (p=0.003), as shown in Table 1.
CPR Duration and ROSC
Approximately 46% of patients did not achieve ROSC after the first cardiac arrest, with a 25.2% survival rate after 28 days. The CPR duration significantly correlated with the achievement of ROSC. The median CPR duration was 7 minutes (IQR: 4-15 minutes) among patients who achieved ROSC, as compared to a median CPR duration of 27 minutes (IQR: 20-44 minutes) among patients who did not achieve ROSC (p<0.001). Shorter CPR durations showed a stronger association with better outcomes, as indicated by the ROC curve analysis. ROC curve analysis showed that CPR duration of more than 15 minutes is a strong predictor of non-ROSC, with 0.866 [95% confidence interval (CI): 0.827-0.899] area under the curve at 82.0% accuracy, 87.0% sensitivity, 77.2% specificity, and p<0.001, as shown in Tables 2 and 3 and Figures 1 and 2.
Post-ROSC Organ Failure
After ROSC from the first cardiac arrest, the most common new organ failure was cardiovascular (18.8%), followed by respiratory (16.2%). However, no significant association was reported between CPR duration and the occurrence of new organ failure post-ROSC (p>0.05). This unexpected result may be influenced by factors not fully accounted for in this study, such as variations in pre-existing conditions, ICU management strategies, or sample size limitations. Additionally, this study did not perform a separate analysis of individual organ systems, which may have masked potential relationships between CPR duration and specific types of organ dysfunction. Future research should examine each organ system separately to better understand how resuscitation efforts influence post-ROSC outcomes.
Survival Beyond 28 Days
In the current study, the survival rate after 28 days was 25.2%. The median age was 4 months (IQR: 3-36) in the survival group, as compared to 8 months (IQR: 1-36) in the non-survival group (p=0.031). The median CPR duration for patients surviving more than 28 days was 5 minutes, as compared to 20 minutes for patients who did not survive (p<0.001). Patients with primary arrest in ER and NICU showed the highest mortality rates (p=0.032 and p=0.036, respectively). Notably, PICU patients showed better survival rates (p=0.002). Furthermore, patients with hepatic failure and sepsis showed higher mortality rates (p=0.032 and p<0.001, respectively), as shown in Table 4.
Multivariate Logistic Regression Analysis
Multivariate logistic regression analysis was performed to identify independent predictors of both return of ROSC and 28-day survival. For ROSC, the analysis revealed that ER arrests (OR=4.12, 95% CI: 1.49-11.41, p=0.006) and increased CPR duration (OR=1.11 per minute, 95% CI: 1.08-1.14, p<0.001) were significantly associated with failure to achieve ROSC.
For 28-day survival, prolonged CPR duration remained a significant predictor of poor outcomes (OR=1.11, 95% CI: 1.07-1.14, p<0.001). Conversely, in the case of post-operative conditions (OR=0.27, 95% CI: 0.14-0.52, p<0.001) or arrhythmia (OR=0.21, 95% CI: 0.06-0.61, p=0.005) as the cause of PICU admission, the results showed a higher association with improved odds of survival, as shown in Table 5.
Discussion
The study evaluated the interplay between CPR duration, initial presenting cardiac rhythm, and arrest location on survival outcomes in pediatric IHCA over ten years. The findings underscore the pivotal role of timely, effective resuscitation in this vulnerable population and highlight the need to enhance both resuscitation and post-resuscitation care. Prolonged CPR duration was significantly associated with poorer outcomes, including lower rates of return of ROSC and reduced 28-day survival. These results align with prior studies demonstrating the critical impact of resuscitation quality on pediatric IHCA outcomes.19-21
The findings do not show a significant relation between prolonged CPR and post-ROSC organ failure. This contradicts published data in adults, which may be related to different physiological responses and varied age-specific management protocols.2 However, other factors may play an essential role, such as pre-existing clinical conditions and the quality of post-arrest care. According to Mally et al.25 the location of arrests appears to be a significant factor influencing outcomes, as arrests in ER exhibited worsened outcomes in comparison to arrests in specialized units such as NICUs and PICUs.14 This difference emphasizes the distinctive challenges encountered in resource-limited ERs and reinforces the necessity of protocol optimization alongside the allocation of resources within such environments.8, 14 Conversely, the results showed no significant correlation between younger age and ROSC, contradicting previous research findings that showed an association between younger age and increased mortality.8
The outcomes of this research align with current literature;3, 12, 13, 20 the initial cardiac rhythm correlated with the research outcomes. Bradycardia with poor perfusion exhibited more favorable outcomes than asystole, highlighting the value of rhythm evaluation and targeted measures.
This highlights the necessity of enhancing healthcare infrastructure in anticipation of possible future worldwide disasters.3, 8, 20, 26 The 28-day survival rate of 25.2% aligns with previous studies, underscoring the significant effectiveness of the post-ROSC phase in specialized care environments such as NICUs and PICUs.8, 20, 26, 27 Thus, it highlights the crucial role of targeted interventions and post-resuscitation strategies.28
The current research highlights numerous clinically actionable targets, such as shortening CPR duration, especially in ER environments. Enhanced team collaboration, continuous uninterrupted chest compressions, and prompt resource access are vital. Furthermore, identifying initial cardiac rhythms and executing rhythm-specific actions are necessary for improving outcomes. The multivariate analysis in the current study revealed significant predictors of pediatric IHCA clinical outcomes. Arrests in ER were significantly correlated with ROSC failure (OR=4.12), aligning with the results of Mally et al.25 Also, prolonged CPR duration significantly correlated with 28-day survival and ROSC (OR=1.11 per minute duration), indicating the value of timely interventions.8 Multivariate regression indicated that longer CPR duration was statistically related to reduced ROSC rates and reduced 28-day survival. However, this relationship does not necessarily indicate a direct cause-and-effect relationship. Instead, longer CPR may serve as a marker of the severity of underlying diseases and not an independent predictor for poor outcomes. This is consistent with previous studies indicating that longer CPR duration tends to be a marker of increased illness severity rather than a direct cause of poor outcomes.29 As a result, multivariate logistic regression was performed in the study, controlling important variables, including the initial cardiac arrest rhythm, site of arrest, and reason for PICU admission (Table 5). The findings suggested that although CPR time continued to be significantly related to ROSC and survival, other clinical variables, including the presenting arrest rhythm and site of the event, also contributed significantly to outcomes.
Better ROSC odds were noted in arrests caused by arrhythmias and in post-operative patients admitted to ICUs, implying possible underlying protective mechanisms. The 28-day survival rate in the current study conforms to the trends reported by Kienzle et al.27 highlighting the necessity of tailored and optimized post-ROSC care. However, the results offer a solid basis for future studies that could incorporate a multi-center research design and integrate further evaluation of targeted interventions to improve CPR quality and duration, especially across ER environments, while further exploring the interaction between factors that influence long-term survival rates and post-arrest quality of life.
Study Limitations
The retrospective design of this study restricts the researcher from establishing a causal relationship between CPR time, initial cardiac rhythm, and IHCA survival outcomes. Furthermore, although the overall sample size of 365 children is large, the statistical power for subgroup analyses, especially comparisons between various arrest types and resuscitation environments (PICU vs. NICU), is still limited. As the study was conducted at a single center, future multicenter studies could improve generalizability.
Conclusion
This study sheds light on key determinants of outcomes in IHCA, addressing significant gaps in existing literature. The research findings emphasize the critical influence of CPR duration, initial cardiac rhythm, and arrest location on both immediate and short-term survival, thus highlighting the pressing need for refined resuscitation strategies, particularly in high-risk scenarios such as ER arrests and cases that require extended CPR. The observed rhythm-specific variations in outcomes reinforce the necessity of tailored, rhythm-focused interventions. The analysis of 28-day survival rates underscores ongoing challenges and the imperative need for improved post-resuscitation care. These insights serve as a robust foundation for developing targeted protocols aimed at enhancing outcomes in pediatric IHCA.
