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Abstract
Problem: Published data on cardiac arrest is mostly focused on the adult population. Our goal is to understand the outcomes and associated factors of survival from cardiac arrests in children and develop a risk score to predict survival. We will also study the decision thresholds of physicians and parents to institute DNAR orders. Methods: We performed a systematic review and meta-analysis to identify pooled survival and factors associated with the survival of out-of-hospital cardiac arrest. We used data from the Get With The Guidelines-Resuscitation registry to identify factors associated with the survival of in-hospital cardiac arrest and developed a risk score. We conducted a survey of physicians and parents in the US to understand their decision thresholds for a child who undergoes cardiac arrest. Results: Our meta-analysis identified 34 studies reporting data from 69,834 pediatric OHCAs. The pooled survival and neurologically intact survival were identified as 13% (95% CI: 11% to 15%) and 6% (95% CI: 5% to 8%) respectively. Predictors of improved survival included witnessed arrest, shockable rhythm, epinephrine use, public location of arrest, bystander CPR, age > 1 year, AED use, and female sex. Delayed EMS response, use of advanced airway in the field and cardiac cause were associated with worse survival. The factors associated with improved survival of IHCA identified from the registry were age, illness category, cardiac malformation, hepatic insufficiency, hypotension, major trauma, metabolic abnormality, metastatic malignancy, renal insufficiency, septicemia, and neurologically intact survival to admission. While found logistic regression to be most useful with AUROCC of 0.70 and 0.71 for infants and older children. In infants, the average probability of survival was 10%, 36%, and 60% whereas in older children it was 6.2%, 31.1%, and 62.3% in the low, moderate, and high survival categories. Our study identified that about 58% of the physicians overestimated the survival than predicted by the model. The decision thresholds for survival to discharge for physicians and parents were 5.3% and 1.2% respectively. Whereas, for neurological survival, these were 3.5% and 0.6% respectively. Parents would still want to resuscitate the child at a survival probability where the physician would recommend withholding resuscitation. Conclusion: we were able to identify factors associated with survival in pediatric OHCA patients. We also identified factors associated with IHCA survival and developed a risk prediction score for pediatric patients with IHCA. We also identified the thresholds below which many physicians and parents would choose a DNAR order.