Post-cardiac arrest physiology and management in the neonatal intensive care unit

Abstract

Aim

The importance of high-quality post-cardiac arrest care is well-described in adult and paediatric populations, but data are lacking to inform post-cardiac arrest care in the neonatal intensive care unit (NICU). The objective of this study was to describe post-cardiac arrest physiology and management in a quaternary NICU.

Methods

Retrospective descriptive study of post-cardiac arrest physiology and management. Data were abstracted from electronic medical records and an institutional resuscitation database. A cardiac arrest was defined as ≥1 minute of chest compressions. Only index arrests were analysed. Descriptive statistics were used to report patient, intra-arrest, and post-arrest characteristics.

Results

There were 110 index cardiac arrests during the 5-year study period from 1/2017–2/2021. The majority (69%) were acute respiratory compromise leading to cardiopulmonary arrest (ARC-CPA) and 26% were primary cardiopulmonary arrests (CPA). Vital sign monitoring within 24 hours post-arrest was variable, especially non-invasive blood pressure frequency (median 5, range 1–44 measurements). There was a high prevalence of hypothermia (73% of arrest survivors). There was substantial variability in laboratory frequency within 24 hours post-arrest. Patients with primary CPA received significantly more lab testing and had a higher prevalence of acidosis (pH < 7.2) than those with ARC-CPA.

Conclusions

We identified significant variation in post-arrest management and a high prevalence of hypothermia. These data highlight the need for post-arrest management guidelines specific to neonatal physiology, as well as opportunities for quality improvement initiatives. Further research is needed to ascertain the impact of neonatal post-arrest management on long-term outcomes and survival.

Introduction

The importance of high-quality, protocolized post-cardiac arrest management is well recognized in adult and paediatric patients. Post-cardiac arrest syndrome is described as a distinct pathophysiologic entity in both adult and paediatric literature. In 2019, the AHA released a scientific statement on paediatric post-arrest care (PCAC) summarizing existing paediatric literature on post-cardiac arrest syndrome and providing recommendations for monitoring, therapeutic strategies, and neuroprognostication in the post-arrest period.[1] In contrast, there are no published studies of post-cardiac arrest physiology or practices in the neonatal intensive care unit (NICU).

In paediatric studies, post-arrest hypotension, hyperthermia, and ventilation and oxygenation abnormalities have been associated with increased mortality and unfavourable neurologic outcomes.2., 3., 4., 5., 6. Neonatal studies of in-unit cardiac arrest have primarily focused on arrest aetiology, characteristics, and outcomes and have not examined post-arrest characteristics.7., 8., 9., 10. Recent studies of CPR in the NICU have demonstrated an 1% incidence of CPR in quaternary NICUs, ten-fold higher than the incidence reported in the delivery room.8., 9., 10. Cardiac arrest in the NICU portends a high risk of mortality and poor neurodevelopmental outcomes, with survival to discharge ranging from 35 to 61%.7., 8., 9. While the Neonatal Resuscitation Program® provides evidence and consensus-based guidelines for delivery room resuscitation and post-delivery care,[11] there are no guidelines for clinical care of the neonate after CPR outside of the delivery room despite the high incidence of CPR and associated poor outcomes among this population.

The objective of this study is to describe post-cardiac arrest physiology and management in a large quaternary NICU.