Long-term neuropsychological outcomes in children and adolescents after cardiac arrest

Prediction of Survival After Pediatric Cardiac Arrest Using Quantitative EEG and Machine Learning Techniques

BACKGROUND AND OBJECTIVES

Early neuroprognostication in children with reduced consciousness after cardiac arrest (CA) is a major clinical challenge. EEG is frequently used for neuroprognostication in adults, but has not been sufficiently validated for this indication in children. Using machine learning techniques, we studied the predictive value of quantitative EEG (qEEG) features for survival 12 months after CA, based on EEG recordings obtained 24 hours after CA in children. The results were confirmed through visual analysis of EEG background patterns.

METHODS

This is a retrospective single-center study including children (0-17 years) with CA, who were subsequently admitted to the pediatric intensive care unit (PICU) of a tertiary care hospital between 2012 and 2021 after return of circulation (ROC) and were monitored using EEG at 24 hours after ROC. Signal features were extracted from a 30-minute EEG segment 24 hours after CA and used to train a random forest model. The background pattern from the same EEG fragment was visually classified. The primary outcome was survival or death 12 months after CA. Analysis of the prognostic accuracy of the model included calculation of receiver-operating characteristic and predictive values. Feature contribution to the model was analyzed using Shapley values.

RESULTS

Eighty-six children were included (in-hospital CA 27%, out-of-hospital CA 73%). The median age at CA was 2.6 years; 53 (62%) were male. Mortality at 12 months was 56%; main causes of death on the PICU were withdrawal of life-sustaining therapies because of poor neurologic prognosis (52%) and brain death (31%). The random forest model was able to predict death at 12 months with an accuracy of 0.77 and positive predictive value of 1.0. Continuity and amplitude of the EEG signal were the signal parameters most contributing to the model classification. Visual analysis showed that no patients with a background pattern other than continuous with amplitudes exceeding 20 μV were alive after 12 months.

DISCUSSION

Both qEEG and visual EEG background classification for registrations obtained 24 hours after ROC form a strong predictor of nonsurvival 12 months after CA in children.

Long-term follow-up in pediatric intensive care-a narrative review

Pediatric intensive care is a rapidly developing medical specialty and with evolving understanding of pediatric pathophysiology and advances in technology, most children in the developed world are now surviving to intensive care and hospital discharge. As mortality rates for children with critical illness continue to improve, increasing PICU survivorship is resulting in significant long-term consequences of intensive care in these vulnerable patients. Although impairments in physical, psychosocial and cognitive function are well documented in the literature and the importance of establishing follow-up programs is acknowledged, no standardized or evidence-based approach to long-term follow-up in the PICU exists. This narrative review explores pediatric post-intensive care syndrome and summarizes the multifactorial deficits and morbidity that can occur in these patients following recovery from critical illness and subsequent discharge from hospital. Current practices around long-term follow-up are explored with discussion focusing on gaps in research and understanding with suggested ways forward and future directions.

An 18-year, single centre, retrospective study of long-term neurological outcomes in paediatric submersion-related cardiac arrests

Aim

Investigate long-term outcome in paediatric submersion-related cardiac arrests (CA).

Methods

Children (age one day-17 years) were included if admitted to the Erasmus MC Sophia Children's Hospital, after drowning with CA, between 2002 and 2019. Primary outcome was survival with favourable neurological outcome, defined as a Paediatric Cerebral Performance Category (PCPC) score of 1-3 at longest available follow-up. Secondary outcome were age-appropriate neuropsychological assessments at longest available follow-up.

Results

Upon hospital admission, 99 children were included (median age at time of CA 3.2 years [IQR 2.0-5.9] and 65% males). Forty children died in-hospital (no return of circulation (45%) or withdrawal of life sustaining therapies (55%)) and 4 children deceased after hospital discharge due to complications following the drowning-incident. Among survivors, with a median follow-up of 2.3 years [IQR 0.2-5.5], 47 children had favourable neurological outcome (i.e. PCPC 1-3) and 8 children unfavourable (unfavourable outcome group total n = 52, i.e. PCPC 4-5 or deceased). Twenty-six (47%) children participated in a neuropsychological assessment (median follow-up 4.0 years [IQR 2.3-8.7]). Compared with normative test data, participants obtained worse general (p = 0.008) and performance (p = 0.003) intelligence scores, processing speed (p = 0.002) and visual motor integration scores (p = 0.0012).

Conclusions

Although overall outcome in survivors was favourable at longest available follow-up, significant deficits in neuropsychological assessments were found. This study underlines the need for a standardized long term follow-up program as standard of care in paediatric drowning with CA.

Survival and neurobehavioral outcomes following out-of-hospital cardiac arrest in pediatric patients with pre-existing morbidity: An analysis of the THAPCA out-of-hospital arrest data

AIM

Pre-arrest morbidity in adults who suffer out-of-hospital cardiac arrest (OHCA) is associated with increased mortality and poorer neurologic outcomes. The objective of this study was to determine if a similar association is seen in pediatric patients.

METHODS

We performed a secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Study sites included 36 pediatric intensive care units across the United States and Canada. The study enrolled children between the ages of 48 hours and 18 years following an OHCA between September 1, 2009 and December 31, 2012. For our analysis, patients with (N = 151) and without (N = 142) pre-arrest comorbidities were evaluated to assess morbidity, survival, and neurologic function following OHCA.

RESULTS

No significant difference in 28-day survival was seen between groups. Dependence on technology and neurobehavioral outcomes were assessed among survivors using the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC). Children with pre-existing comorbidities maintained worse neurobehavioral function at twelve months, evidenced by poorer scores on POPC (p = 0.016), PCPC (p = 0.044), and VABS-II (p = 0.020). They were more likely to have a tracheostomy at hospital discharge (p = 0.034), require supplemental oxygen at three months (p = 0.039) and twelve months (p = 0.034), and be mechanically ventilated at twelve months (p = 0.041).

CONCLUSIONS

There was no difference in survival to 28 days following OHCA in children with pre-existing comorbidity compared to previously healthy children. The group with pre-existing comorbidity was more reliant on technology following arrest and exhibited worse neurobehavioral outcomes.

Trends in community response and long-term outcomes from pediatric cardiac arrest: A retrospective observational study

AIM

This study aimed to investigate trends over time in pre-hospital factors for pediatric out-of-hospital cardiac arrest (pOHCA) and long-term neurological and neuropsychological outcomes. These have not been described before in large populations.

METHODS

Non-traumatic arrest patients, 1 day-17 years old, presented to the Sophia Children's Hospital from January 2002 to December 2020, were eligible for inclusion. Favorable neurological outcome was defined as Pediatric Cerebral Performance Categories (PCPC) 1-2 or no difference with pre-arrest baseline. The trend over time was tested with multivariable logistic and linear regression models with year of event as independent variable.

FINDINGS

Over a nineteen-year study period, the annual rate of long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, increased significantly (OR 1.10, 95%-CI 1.03-1.19), adjusted for confounders. Concurrently, annual automated external defibrillator (AED) use and, among adolescents, initial shockable rhythm increased significantly (OR 1.21, 95% CI 1.10-1.33 and OR 1.15, 95% CI 1.02-1.29, respectively), adjusted for confounders. For generalizability purposes, only the total intelligence quotient (IQ) was considered for trend analysis of all tested domains. Total IQ scores and bystander basic life support (BLS) rate did not change significantly over time.

INTERPRETATION

Long-term favorable neurological outcome, assessed at a median 2.5 years follow-up, improved significantly over the study period. Total IQ scores did not significantly change over time. Furthermore, AED use (OR 1.21, 95%CI 1.10-1.33) and shockable rhythms among adolescents (OR1.15, 95%CI 1.02-1.29) increased over time.

Follow-up after PICU discharge for patients with acquired brain injury: the role of an abbreviated neuropsychological evaluation and a return-to-school program

Objective

To present the results of an abbreviated testing protocol used to screen for neurocognitive and psychological sequelae of critical illness among pediatric intensive care unit (PICU) survivors with acquired brain injury in our post-discharge follow-up programs, and describe our process for facilitating this population's return to academic life.

Design

Retrospective cohort study.

Setting

Neurocritical care follow-up programs at two U.S. academic, tertiary medical/surgical PICUs.

Patients

Children age > 4 years enrolled in the neurocritical care follow-up programs (n=289) at these institutions who underwent neurocognitive and psychological testing between 2017-2021.

Interventions

None.

Measurements and Main Results

One month after discharge from the hospital, nearly half of the children and/or their parents (48%) in our neurocritical care follow-up programs identified some type of emotional or behavioral concern compared to their premorbid state, and 15% reported some type of cognitive concern. On evaluation, 35% of the children were given a new neurocognitive diagnosis. Neurocognitive domains regulated by the executive functioning system were the most commonly affected, including attention (54%), memory (31%) and processing speed (27%). One-quarter of the children were given a new psychological diagnosis, most commonly post-traumatic stress disorder (PTSD) or stress-related symptoms (12%). Over 80% of patients in the programs were given new recommendations for school, for both new academic services and new classroom accommodations. Over half of children (57%) were referred for comprehensive follow-up neuropsychological evaluation.

Conclusions

Abbreviated neurocognitive and psychological evaluation successfully identifies the same deficits commonly found among PICU survivors who undergo longer, more complete testing protocols. When combined with services aimed at successfully re-integrating PICU survivors back to school, this focused evaluation can provide an effective and efficient means of screening for cognitive and emotional deficits among PICU survivors, and establish a rationale for early academic support upon the child's return to school.

Video Review of Simulated Pediatric Cardiac Arrest to Identify Errors/Latent Safety Threats: A Mixed Methods Study

INTRODUCTION

Outcomes from pediatric in-hospital cardiac arrest depend on the treatment provided as well as resuscitation team performance. Our study aimed to identify errors occurring in this clinical context and develop an analytical framework to classify them. This analytical framework provided a better understanding of team performance, leading to improved patient outcomes.

METHODS

We analyzed 25 video recordings of pediatric cardiac arrest simulations from the pediatric intensive care unit at the Alberta Children's Hospital. We conducted a qualitative-dominant crossover mixed method analysis to produce a broad understanding of the etiology of errors. Using qualitative framework analysis, we identified and qualitatively described errors and transformed the data coded into quantitative data to determine the frequency of errors.

RESULTS

We identified 546 errors/error-related actions and behaviors and 25 near misses. The errors were coded into 21 codes that were organized into 5 main themes. Clinical task-related errors accounted for most errors (41.9%), followed by planning, and executing task-related errors (22.3%), distraction-related errors (18.7%), communication-related errors (10.1%), and knowledge/training-related errors (7%).

CONCLUSIONS

This novel analytical framework can robustly identify, classify, and describe the root causes of errors within this complex clinical context. Future validation of this classification of errors and error-related actions and behaviors on larger samples of resuscitations from various contexts will allow for a better understanding of how errors can be mitigated to improve patient outcomes.

Association of EEG and Blood-Based Brain Injury Biomarker Accuracy to Prognosticate Mortality After Pediatric Cardiac Arrest: An Exploratory Study

BACKGROUND

Evaluate the accuracy of brain-based blood biomarkers neuron-specific enolase (NSE) and S100b and electroencephalography (EEG) features alone and in combination with prognosticate 6-month mortality after pediatric cardiac arrest. We hypothesized that the combination of blood brain-based biomarkers and EEG features would have superior classification accuracy of outcome versus either alone.

METHODS

Children (n = 58) aged between 1 week and 17 years admitted to the ICU following cardiac arrest at a tertiary care children's hopital were eligible for this secondary study. Blood NSE and S100b were measured closest to 24 hours after return of spontaneous circulation (ROSC). EEGs closest to 24 hours (median 11, interquartile range [IQR] 6 to 16 h) post-ROSC were evaluated by two epileptologists. EEG grade was informed by background frequency, amplitude, and continuity. Sleep spindles were present or absent. Mortality was assessed at six months post-ROSC. Area under the receiver operator curve (AUC) was performed for individual and combined brain-based biomarkers and EEG features.

RESULTS

Children were aged 2.6 (IQR 0.6 to 10.4) years, and 25 (43%) died. Children who died had increased blood NSE (49.7 [28.0 to 63.1] vs 18.2 [9.8 to 31.8] ng/mL) and S100b (0.118 [0.036 to 0.296] vs 0.012 [0.003 to 0.021] ng/mL) and poor (discontinuous or isoelectric) EEG grade (76% vs 33%) more frequently than survivors (P < 0.05). AUC for NSE to predict mortality was 0.789, and was 0.841 when combined with EEG grade and spindles. S100b AUC for mortality was 0.856 and was optimal alone.

CONCLUSIONS

In this exploratory study, the combination of brain-based biomarkers and EEG features may provide more accurate prognostication than either test alone after pediatric cardiac arrest.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Long-Term Outcomes after Non-Traumatic Out-of-Hospital Cardiac Arrest in Pediatric Patients: A Systematic Review

Long-term outcomes after non-traumatic pediatric out-of-hospital cardiac arrest (OHCA) are not well understood. This systematic review aimed to summarize long-term outcomes (1 year and beyond), including overall survival, survival with favorable neurological outcomes, and health-related quality of life (HRQoL) outcomes) amongst pediatric OHCA patients who survived to discharge. Embase, Medline, and The Cochrane Library were searched from inception to October 6, 2021. Studies were included if they reported outcomes at 1 year or beyond after pediatric OHCA. Data abstraction and quality assessment was conducted by three authors independently. Qualitative outcomes were reported systematically. Seven studies were included, and amongst patients that survived to hospital discharge or to 30 days, longer-term survival was at least 95% at 24 months of follow up. A highly variable proportion (range 10–71%) of patients had favorable neurological outcomes at 24 months of follow up. With regard to health-related quality of life outcomes, at a time point distal to 1 year, at least 60% of pediatric non-traumatic OHCA patients were reported to have good outcomes. Our study found that at least 95% of pediatric OHCA patients, who survived to discharge, survived to a time point distal to 1 year. There is a general paucity of data surrounding the pediatric OHCA population.

Cognitive and Psychological Outcomes Following Pediatric Cardiac Arrest

Cardiac arrest is a rare event in children and adolescents. Those who survive may experience a range of outcomes, from good functional recovery to severe and permanent disability. Many children experience long-term cognitive impairment, including deficits in attention, language, memory, and executive functioning. Deficits in adaptive behavior, such as motor functioning, communication, and daily living skills, have also been reported. These children have a wide range of neurological outcomes, with some experiencing specific deficits such as aphasia, apraxia, and sensorimotor deficits. Some children may experience emotional and psychological difficulties, although many do not, and more research is needed in this area. The burden of pediatric cardiac arrest on the child's family and caregivers can be substantial. This narrative review summarizes current research regarding the cognitive and psychological outcomes following pediatric cardiac arrest, identifies areas for future research, and discusses the needs of these children for rehabilitation services and academic accommodations.

Neuropsychological and Psychosocial Functioning of Children with Perinatal HIV-Infection in The Netherlands

Advances in antiretroviral treatment improved the life expectancy of perinatally HIV-infected children. However, growing up with HIV provides challenges in daily functioning. This cross-sectional cohort study investigated the neuropsychological and psychosocial functioning of a group of perinatally HIV-infected children in the Netherlands and compared their outcomes with Dutch normative data and outcomes of a control group of uninfected siblings. The children’s functioning was assessed with internationally well-known and standardized questionnaires, using a multi-informant approach, including the perspectives of caregivers, teachers, and school-aged children. In addition, we explored the associations of socio-demographic and medical characteristics of the HIV-infected children with their neuropsychological and psychosocial functioning. Caregivers reported compromised functioning when compared to Dutch normative data for HIV-infected children in the areas of attention, sensory processing, social-emotional functioning, and health-related quality of life. Teachers reported in addition compromised executive functioning for HIV-infected children. A comparison with siblings revealed differences in executive functioning, problems with peers, and general health. The concurrent resemblance between HIV-infected children and siblings regarding problems in other domains implies that social and contextual factors may be of influence. A family-focused approach with special attention to the child’s socio-environmental context and additional attention for siblings is recommended.

Longitudinal two years evaluation of neuropsychological outcome in children after out of hospital cardiac arrest

AIM

To investigate longitudinal functional and neuropsychological outcomes 3-6 and 24 months after paediatric out-of-hospital cardiac arrest (OHCA). Further, to explore the association between paediatric cerebral performance category (PCPC) and intelligence.

METHODS

Prospective longitudinal single center study including children (0-17 years) with OHCA, admitted to the PICU of a tertiary care hospital between 2012 and 2017. Survivors were assessed during an outpatient multidisciplinary follow-up program 3-6 and 24 months post-OHCA. Functional and neuropsychological outcomes were assessed through interviews, neurological exam, and validated neuropsychological testing.

RESULTS

The total eligible cohort consisted of 49 paediatric OHCA survivors. The most common cause of OHCA was arrhythmia (33%). Median age at time of OHCA was 48 months, 67% were males. At 3-6 and 24 months post-OHCA, respectively 74 and 73% had a good PCPC score, defined as 1-2. Compared with normative data, OHCA children obtained worse sustained attention and processing speed scores 3-6 (n = 26) and 24 (n = 27) months post-OHCA. At 24 months, they also obtained worse intelligence, selective attention and cognitive flexibility scores. In children tested at both time-points (n = 19), no significant changes in neuropsychological outcomes were found over time. Intelligence scores did not correlate with PCPC.

CONCLUSION

Although paediatric OHCA survivors had a good PCPC score 3-6 and 24 months post-OHCA, they obtained worse scores on important neuropsychological domains such as intelligence and executive functioning (attention and cognitive flexibility). Follow-up should continue over a longer life span in order to fully understand the long-term impact of OHCA in childhood.

Association between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: An 18-year observational study

INTRODUCTION

Shockable rhythm following pediatric out-of-hospital cardiac arrest (pOHCA) is consistently associated with hospital and short-term survival. Little is known about the relationship between shockable rhythm and long-term outcomes (>1 year) after pOHCA. The aim was to investigate the association between first documented rhythm and long-term outcomes in a pOHCA cohort over 18 years.

METHODS

All children aged 1 day-18 years who experienced non-traumatic pOHCA between 2002-2019 and were subsequently admitted to the emergency department (ED) or pediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital were included. Data was abstracted retrospectively from patient files, (ground) ambulance and Helicopter Emergency Medical Service (HEMS) records, and follow-up clinics. Long-term outcome was determined using a Pediatric Cerebral Performance Category (PCPC) score at the longest available follow-up interval through august 2020. The primary outcome measure was survival with favorable neurologic outcome, defined as PCPC 1-2 or no difference between pre- and post-arrest PCPC. The association between first documented rhythm and the primary outcome was calculated in a multivariable regression model.

RESULTS

369 children were admitted, nine children were lost to follow-up. Median age at arrest was age 3.4 (IQR 0.8-9.9) years, 63% were male and 14% had a shockable rhythm (66% non-shockable, 20% unknown or return of spontaneous circulation (ROSC) before emergency medical service (EMS) arrival). In adolescents (aged 12-18 years), 39% had shockable rhythm. 142 (39%) of children survived to hospital discharge. On median follow-up interval of 25 months (IQR 5.1-49.6), 115/142 (81%) of hospital survivors had favorable neurologic outcome. In multivariable analysis, shockable rhythm was associated with survival with favorable long-term neurologic outcome (OR 8.9 [95%CI 3.1-25.9]).

CONCLUSION

In children with pOHCA admitted to ED or PICU shockable rhythm had significantly higher odds of survival with long-term favorable neurologic outcome compared to non-shockable rhythm. Survival to hospital discharge after pOHCA was 39% over the 18-year study period. Of survivors to discharge, 81% had favorable long-term (median 25 months, IQR 5.1-49.6) neurologic outcome. Efforts for improving outcome of pOHCA should focus on early recognition and treatment of shockable pOHCA at scene.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation

Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

Using ICF-CY WHO principles to guide rehabilitation following sudden cardiac arrest in an adolescent with ALCAPA

This case report details the complex rehabilitation of an adolescent patient with congenital heart disease with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) who presented with a sudden cardiac arrest. The International Classification of Functioning, Disability and Health for Children and Youth, World Health Organization (ICF-CY WHO) principles were used to guide the course of the patient's acute inpatient rehabilitation.

P-COSCA (Pediatric Core Outcome Set for Cardiac Arrest) in Children: An Advisory Statement From the International Liaison Committee on Resuscitation

Studies of pediatric cardiac arrest use inconsistent outcomes, including return of spontaneous circulation and short-term survival, and basic assessments of functional and neurological status. In 2018, the International Liaison Committee on Resuscitation sponsored the COSCA initiative (Core Outcome Set After Cardiac Arrest) to improve consistency in reported outcomes of clinical trials of adult cardiac arrest survivors and supported this P-COSCA initiative (Pediatric COSCA). The P-COSCA Steering Committee generated a list of potential survival, life impact, and economic impact outcomes and assessment time points that were prioritized by a multidisciplinary group of healthcare providers, researchers, and parents/caregivers of children who survived cardiac arrest. Then expert panel discussions achieved consensus on the core outcomes, the methods to measure those core outcomes, and the timing of the measurements. The P-COSCA includes assessment of survival, brain function, cognitive function, physical function, and basic daily life skills. Survival and brain function are assessed at discharge or 30 days (or both if possible) and between 6 and 12 months after arrest. Cognitive function, physical function, and basic daily life skills are assessed between 6 and 12 months after cardiac arrest. Because many children have prearrest comorbidities, the P-COSCA also includes documentation of baseline (ie, prearrest) brain function and calculation of changes after cardiac arrest. Supplementary outcomes of survival, brain function, cognitive function, physical function, and basic daily life skills are assessed at 3 months and beyond 1 year after cardiac arrest if resources are available.

Early EEG Features for Outcome Prediction After Cardiac Arrest in Children

PURPOSE

We aimed to determine which early EEG features and feature combinations most accurately predicted short-term neurobehavioral outcomes and survival in children resuscitated after cardiac arrest.

METHODS

This was a prospective, single-center observational study of infants and children resuscitated from cardiac arrest who underwent conventional EEG monitoring with standardized EEG scoring. Logistic regression evaluated the marginal effect of each EEG variable or EEG variable combinations on the outcome. The primary outcome was neurobehavioral outcome (Pediatric Cerebral Performance Category score), and the secondary outcome was mortality. The authors identified the models with the highest areas under the receiver operating characteristic curve (AUC), evaluated the optimal models using a 5-fold cross-validation approach, and calculated test characteristics maximizing specificity.

RESULTS

Eighty-nine infants and children were evaluated. Unfavorable neurologic outcome (Pediatric Cerebral Performance Category score 4-6) occurred in 44 subjects (49%), including mortality in 30 subjects (34%). A model incorporating a four-level EEG Background Category (normal, slow-disorganized, discontinuous or burst-suppression, or attenuated-flat), stage 2 Sleep Transients (present or absent), and Reactivity-Variability (present or absent) had the highest AUC. Five-fold cross-validation for the optimal model predicting neurologic outcome indicated a mean AUC of 0.75 (range, 0.70-0.81) and for the optimal model predicting mortality indicated a mean AUC of 0.84 (range, 0.76-0.97). The specificity for unfavorable neurologic outcome and mortality were 95% and 97%, respectively. The positive predictive value for unfavorable neurologic outcome and mortality were both 86%.

CONCLUSIONS

The specificity of the optimal model using a combination of early EEG features was high for unfavorable neurologic outcome and mortality in critically ill children after cardiac arrest. However, the positive predictive value was only 86% for both outcomes. Therefore, EEG data must be considered in overall clinical context when used for neuroprognostication early after cardiac arrest.

Neuropsychological Outcomes of Children 1 Year After Pediatric Cardiac Arrest: Secondary Analysis of 2 Randomized Clinical Trials

Importance

Little is known about neuropsychological outcomes of children who survived pediatric cardiac arrest (CA).

Objective

To describe the neuropsychological outcomes of CA survivors enrolled in the Therapeutic Hypothermia After Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) and Out-of-Hospital (THAPCA-OH) trials and compare the results with the primary outcome measure for these trials.

Design, Setting, and Participants

Secondary analysis of 222 CA survivors aged 1 to 18 years who received chest compressions for 2 minutes or more, remained comatose and required mechanical ventilation after return of circulation, and were enrolled in targeted temperature-management trials from 41 pediatric intensive care units. Data were collected from September 3, 2009, to February 3, 2016, and analyzed from March 10, 2017, to April 20, 2018.

Main Outcomes and Measures

The Vineland Adaptive Behavior Scales, Second Edition (VABS-II), a standardized measure of neurobehavioral functioning based on caregiver report (age-corrected mean [SD] scores = 100 [15]), was used to evaluate pre-CA functioning within 24 hours after enrollment; VABS-II<70 indicated significant developmental delays; VABS-II and neuropsychological testing were completed 1 year after CA. Neuropsychological testing included the Mullen Scales of Early Learning (Mullen) for children younger than 6 years and the Wechsler Abbreviated Scale of Intelligence (WASI) and neuropsychological measures of attention, memory, processing speed, and executive functioning for older children.

Results

Of 160 participants who completed neuropsychological testing, 96 (60.0%) were male; the median (interquartile range [IQR]) age was 2.5 years (1.3-6.1 years). Ninety-six (60.0%) were white, 41 (25.6%) were black, and 23 (14.4%) were of other/unknown race; 343 (21.2%) were Hispanic or Latino; 119 (74.4%) were non-Hispanic or Latino; and 7 (4.4%) were of unknown ethnicity. One hundred fourteen participants (71.2%) were classified as having favorable outcomes (VABS-II ≥70). Impairments (>2 SD below the mean for age) across neuropsychological measures ranged from 7% to 61%. Correlations between global cognitive and VABS-II scores were strong for younger children (Mullen, r = 0.69-0.87) but moderate for older children (r = 0.21-0.54 for the WASI). Of 111 children with favorable outcomes on VABS-II, 25.2% had global cognitive impairment and 30 of 35 older children (85.7%) had selective neuropsychological deficits.

Conclusions and Relevance

In this prospectively evaluated cohort of pediatric CA survivors who were initially comatose, although 71.2% were classified as having favorable outcomes, significant neuropsychological deficits were identified in pediatric CA survivors who were classified as having favorable outcomes. The findings provide clinicians with a greater understanding of the spectrum of neuropsychological outcomes of pediatric CA survivors and the complex relationship between standardized caregiver-reported functional outcome measures incorporated in clinical trials and performance-based neuropsychological assessments.

Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

The association of early post-resuscitation hypotension with discharge survival following targeted temperature management for pediatric in-hospital cardiac arrest

AIM

Approximately 40% of children who have an in-hospital cardiac arrest (IHCA) in the US survive to discharge. We aimed to evaluate the impact of post-cardiac arrest hypotension during targeted temperature management following IHCA on survival to discharge.

METHODS

This is a secondary analysis of the therapeutic hypothermia after pediatric cardiac arrest in-hospital (THAPCA-IH) trial. "Early hypotension" was defined as a systolic blood pressure less than the fifth percentile for age and sex for patients not treated with extracorporeal membrane oxygenation (ECMO) or a mean arterial pressure less than fifth percentile for age and sex for patients treated with ECMO during the first 6 h of temperature intervention. The primary outcome was survival to hospital discharge.

RESULTS

Of 299 children, 142 (47%) patients did not receive ECMO and 157 (53%) received ECMO. Forty-two of 142 (29.6%) non-ECMO patients had systolic hypotension. Twenty-three of 157 (14.7%) ECMO patients had mean arterial hypotension. After controlling for confounders of interest, non-ECMO patients who had early systolic hypotension were less likely to survive to hospital discharge (40.5% vs. 72%; adjusted OR [aOR] 0.34; 95%CI, 0.12-0.93). There was no difference in survival to discharge by blood pressure groups for children treated with ECMO (30.4% vs. 49.3%; aOR = 0.60; 95%CI, 0.22-1.63).

CONCLUSIONS

In this secondary analysis of the THAPCA-IH trial, in patients not treated with ECMO, systolic hypotension within 6 h of temperature intervention was associated with lower odds of discharge survival. Blood pressure groups in patients treated with ECMO were not associated with survival to discharge.

Quantitative EEG predicts outcomes in children after cardiac arrest

OBJECTIVE

To determine whether quantitative EEG (QEEG) features predict neurologic outcomes in children after cardiac arrest.

METHODS

We performed a single-center prospective observational study of 87 consecutive children resuscitated and admitted to the pediatric intensive care unit after cardiac arrest. Full-array conventional EEG data were obtained as part of clinical management. We computed 8 QEEG features from 5-minute epochs every hour after return of circulation. We developed predictive models utilizing random forest classifiers trained on patient age and 8 QEEG features to predict outcome. The features included SD of each EEG channel, normalized band power in alpha, beta, theta, delta, and gamma wave frequencies, line length, and regularity function scores. We measured outcomes using Pediatric Cerebral Performance Category (PCPC) scores. We evaluated the models using 5-fold cross-validation and 1,000 bootstrap samples.

RESULTS

The best performing model had a 5-fold cross-validation accuracy of 0.8 (0.88 area under the receiver operating characteristic curve). It had a positive predictive value of 0.79 and a sensitivity of 0.84 in predicting patients with favorable outcomes (PCPC score of 1-3). It had a negative predictive value of 0.8 and a specificity of 0.75 in predicting patients with unfavorable outcomes (PCPC score of 4-6). The model also identified the relative importance of each feature. Analyses using only frontal electrodes did not differ in prediction performance compared to analyses using all electrodes.

CONCLUSIONS

QEEG features can standardize EEG interpretation and predict neurologic outcomes in children after cardiac arrest.

Developmental Outcome in Infants with Cardiovascular Disease After Cardiopulmonary Resuscitation: A Pilot Study

Unfavorable neurological outcome in children after cardiopulmonary resuscitation in infancy is frequent. However, few studies have investigated the development of these patients using comprehensive developmental tests and the feasibility of the Bayley Scales of Infant Development, 3rd Edition (BSID-III) has not been reported for this population. In this cross-sectional pilot study, we assessed the cognitive, language, and motor development in infants after cardiopulmonary resuscitation of ≥ 5 min with the BSID-III at the age of 12 or 24 months, depending on recruitment age. For analysis, 11 patients with in-hospital (n = 8) and out-of-hospital (n = 3) cardiac arrest were included. BSID-III results could not be quantified in three patients because of visual/hearing and/or motor impairment. In patients with quantifiable scores, 50.0% scored average in composite BSID-III scores, while the other 50.0% showed developmental delays, scoring distinctly below average. We conclude that the BSID-III is feasible for developmental assessment in the majority of the study population, but the use of instruments suitable for hearing/visually impaired and/or severely disabled infants is crucial to avoid biased results. Accurate characterization of developmental deficits is important to facilitate early identification and therapy of deficits.

The prognostic value of quantitative diffusion-weighted MRI after pediatric cardiopulmonary arrest

OBJECTIVES

The prognostic value of quantitative diffusion-weighted magnetic resonance imaging (DWI MRI) in predicting neurologic outcomes after pediatric cardiopulmonary arrest (CPA) has not been determined. The aim of this study was to identify a DWI MRI threshold for brain volume percent that correlates with neurologic outcome in children who remain comatose or display significant neurologic deficits immediately after resuscitation from CPA.

METHODS

This single-center retrospective study analyzed DWI MRIs of pediatric patients who remained neurologically impaired after CPA. Any MRI obtained within 2 weeks after CPA was analyzed. The apparent diffusion coefficient (ADC) value of each voxel within the brain was determined. Percentage brain volume with voxels below each ADC threshold between 300 and 1200 × 10^-6 mm²/s with a step of 50 were calculated. Area under the receiver operating characteristics curve (AUC) was used to identify optimal DWI MRI thresholds for brain volume percent most predictive of poor neurologic outcome. The primary outcome measure was neurologic outcome 6-months after CPA based on Pediatric Cerebral Performance Category (PCPC) score. Poor neurologic outcome was defined as PCPC score of 3-6, or a worsening from baseline score ≥1 if baseline PCPC score was ≥3.

RESULTS

Twenty-six patients were included in this study. The median age was 8.5 years (2.2-14) and median time from CPA to MRI was 4 days (2-7). Two ADC thresholds for brain volume percent had the largest AUC for predicting poor neurologic outcome. An ADC threshold of <600 × 10^-6 mm²/s in ≥7% of brain volume; and <650 × 10^-6 mm²/s in ≥11% of brain volume both demonstrated a specificity of 1.0 (0.76-1.0, 95% CI) and a sensitivity of 0.8 (0.44-0.96, 95% CI) for poor outcome.

CONCLUSIONS

In pediatric patients who remain comatose or have significant neurologic deficits after CPA, quantitative DWI MRI correlates with neurologic outcome. Both an ADC threshold of <600 × 10^-6 mm²/s in ≥7% of brain volume and <650 × 10^-6 mm²/s in ≥11% of brain volume are highly specific for predicting poor neurologic outcome. A prospective trial to validate these thresholds is needed.

Stability of Early EEG Background Patterns After Pediatric Cardiac Arrest

PURPOSE

We aimed to determine whether EEG background characteristics remain stable across discrete time periods during the acute period after resuscitation from pediatric cardiac arrest.

METHODS

Children resuscitated from cardiac arrest underwent continuous conventional EEG monitoring. The EEG was scored in 12-hour epochs for up to 72 hours after return of circulation by an electroencephalographer using a Background Category with 4 levels (normal, slow-disorganized, discontinuous/burst-suppression, or attenuated-featureless) or 2 levels (normal/slow-disorganized or discontinuous/burst-suppression/attenuated-featureless). Survival analyses and mixed-effects ordinal logistic regression models evaluated whether the EEG remained stable across epochs.

RESULTS

EEG monitoring was performed in 89 consecutive children. When EEG was assessed as the 4-level Background Category, 30% of subjects changed category over time. Based on initial Background Category, one quarter of the subjects changed EEG category by 24 hours if the initial EEG was attenuated-featureless, by 36 hours if the initial EEG was discontinuous or burst-suppression, by 48 hours if the initial EEG was slow-disorganized, and never if the initial EEG was normal. However, regression modeling for the 4-level Background Category indicated that the EEG did not change over time (odds ratio = 1.06, 95% confidence interval = 0.96-1.17, P = 0.26). Similarly, when EEG was assessed as the 2-level Background Category, 8% of subjects changed EEG category over time. However, regression modeling for the 2-level category indicated that the EEG did not change over time (odds ratio = 1.02, 95% confidence interval = 0.91-1.13, P = 0.75).

CONCLUSIONS

The EEG Background Category changes over time whether analyzed as 4 levels (30% of subjects) or 2 levels (8% of subjects), although regression analyses indicated that no significant changes occurred over time for the full cohort. These data indicate that the Background Category is often stable during the acute 72 hours after pediatric cardiac arrest and thus may be a useful EEG assessment metric in future studies, but that some subjects do have EEG changes over time and therefore serial EEG assessments may be informative.

Timing and modes of death after pediatric out-of-hospital cardiac arrest resuscitation

AIM

To determine the timing and modes of death of children admitted to a pediatric critical care unit (PICU) of a tertiary care center after an out-of-hospital cardiac arrest (OHCA).

METHODS

This is a retrospective descriptive study at a tertiary care PICU of all consecutive patients <18 years old who received ≥1 min of chest compressions, had return of spontaneous circulation (ROSC) for ≥20 min, and were admitted to the PICU after an OHCA. Modes of death were classified as brain death (BD), withdrawal due to neurologic prognosis (W/D-neuro), withdrawal for refractory circulatory failure (W/D-RCF), and re-arrest without ROSC (RA).

RESULTS

191 consecutive patients were admitted to the PICU from February 2005 to May 2013 after an OHCA. Eighty-six(45%) patients died prior to discharge: BD in 47%(40/86), W/D-neuro in 34%(29/86), W/D-RCF in 10%(9/86), and RA in 9%(8/86). Time to death was longer for patients with W/D-neuro: 4 days [1, 5] and BD 4 days [1, 5](p < 0.01) as opposed to those with W/D-RCF (1 day[1, 2]) and RA(1 day[0.5, 1]). Of patients who underwent W/D-neuro, 9/29(31%) died within 3 days of PICU admission and 20/29(69%) ≥3 days. Of patients who died after W/D-neuro, 12/29(41%) received therapeutic hypothermia, 27/29(93%) underwent EEG monitoring, 21/29(72%) had a brain CT, and 13/29(45%) had a brain MRI. All MRIs showed signs of hypoxic-ischemic injury.

CONCLUSION

Neurologic injury was the most common mode of death post-resuscitation care OHCA after in a tertiary care center PICU. Neurologic prognostication impacts the outcome of a large proportion of patients after OHCA, and further studies are warranted to improve its reliability.

Interrater Agreement of EEG Interpretation After Pediatric Cardiac Arrest Using Standardized Critical Care EEG Terminology

PURPOSE

We evaluated interrater agreement of EEG interpretation in a cohort of critically ill children resuscitated after cardiac arrest using standardized EEG terminology.

METHODS

Four pediatric electroencephalographers scored 10-minute EEG segments from 72 consecutive children obtained 24 hours after return of circulation using the American Clinical Neurophysiology Society's (ACNS) Standardized Critical Care EEG terminology. The percent of perfect agreement and the kappa coefficient were calculated for each of the standardized EEG variables and a predetermined composite EEG background category.

RESULTS

The overall background category (normal, slow-disorganized, discontinuous, or attenuated-featureless) had almost perfect agreement (kappa 0.89).The ACNS Standardized Critical Care EEG variables had agreement that was (1) almost perfect for the seizures variable (kappa 0.93), (2) substantial for the continuity (kappa 0.79), voltage (kappa 0.70), and sleep transient (kappa 0.65) variables, (3) moderate for the rhythmic or periodic patterns (kappa 0.55) and interictal epileptiform discharge (kappa 0.60) variables, and (4) fair for the predominant frequency (kappa 0.23) and symmetry (kappa 0.31) variables. Condensing variable options led to improved agreement for the continuity and voltage variables.

CONCLUSIONS

These data support the use of the standardized terminology and the composite overall background category as a basis for standardized EEG interpretation for subsequent studies assessing EEG background for neuroprognostication after pediatric cardiac arrest.

Association of Early Postresuscitation Hypotension With Survival to Discharge After Targeted Temperature Management for Pediatric Out-of-Hospital Cardiac Arrest: Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post-cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described during targeted temperature management.

OBJECTIVE

To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA.

DESIGN, SETTING, AND PARTICIPANTS

This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1, 2009, through December 31, 2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5, 2016, through June 13, 2017.

EXPOSURES

Hypotension.

MAIN OUTCOMES AND MEASURE

Survival to hospital discharge.

RESULTS

Of 292 children (194 boys [66.4%] and 98 girls [33.6%]; median age, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) or rewarming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74).

CONCLUSIONS AND RELEVANCE

In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post-cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.

Neurobehavioural outcomes in children after In-Hospital cardiac arrest

AIM

Children who remain comatose after in-hospital cardiac arrest (IH-CA) resuscitation are at risk for poor neurological outcome. We report results of detailed neurobehavioural testing in paediatric IH-CA survivors, initially comatose after return of circulation, and enrolled in THAPCA-IH, a clinical trial that evaluated two targeted temperature management interventions (hypothermia, 33.0 °C or normothermia, 36.8 °C; NCT00880087).

METHODS

Children, aged 2 days to <18 years, were enrolled in THAPCA-IH from 2009 to 2015; primary trial outcome (survival with favorable neurobehavioural outcome) did not differ between groups. Pre-IH-CA neurobehavioural functioning, measured with the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) was evaluated soon after enrollment; this report includes only children with broadly normal pre-IH-CA scores (VABS-II composite scores ≥70; 269 enrolled). VABS-II was re-administered 3 and 12 months later. Cognitive testing was completed at 12 months.

RESULTS

Follow-ups were obtained on 125 of 135 eligible one-year survivors. Seventy-seven percent (96/125) had VABS-II scores ≥70 at 12 months; cognitive composites were ≥2SD of mean in 59%. VABS-II composite, domain, and most subdomain scores declined between pre-IH-CA and 3-month, and pre-IH-CA and 12-month assessments (composite means declined about 1 SD at 3 and 12 months, p < 0.005); 3 and 12-month scores were strongly correlated (r = 0.72, p < 0.001).

CONCLUSIONS

In paediatric IH-CA survivors at high risk for unfavorable outcomes, the majority demonstrated significant declines in neurobehavioural functioning, across multiple functional domains, with similar functioning at 3 and 12 months. About three-quarters attained VABS-II functional performance composite scores within the broadly normal range.

Psychological and Psychiatric Outcomes Following PICU Admission: A Systematic Review of Cohort Studies

OBJECTIVE

Admissions to PICU places pediatric patients at increased risk of persistent psychological and psychiatric morbidity. This systematic review aimed to summarize and critically examine literature regarding psychological and psychiatric outcomes of pediatric patients following PICU admission.

DATA SOURCES

MEDLINE, Web of Science, Cochrane Library, Science Direct, PsycInfo, CINAHL, LILACS, and SciELO were searched up to May 2016.

STUDY SELECTION

Cohort studies about psychological and psychiatric outcomes of pediatric patients following PICU admission; full-text records published in English, Spanish, or Portuguese in peer-reviewed journals from 2000 to 2015 were included. Neonatal patient population (age, <1 mo), follow-up after PICU discharge (<3 mo), and nonprimary literature were excluded. Two reviewers independently screened studies based on the predetermined exclusion criteria.

DATA EXTRACTION

Data were extracted using an adapted tool. The internal validity and risk of bias were assessed using Newcastle-Ottawa Scale.

DATA SYNTHESIS

The search yielded 1,825 studies after the removal of duplications, of which eight met the inclusion criteria. Methodologic quality of the studies ranged from low to high, with an average score of five of nine. Of all the studies, half had a control group. Regarding the length of follow-up, most of the studies ranged from 3 to 12 months.

CONCLUSIONS

Psychological and psychiatric outcomes after pediatric critical illness appear to be substantial issues that need to be further studied. Our review highlights the need for psychological screening of pediatric patients and their parents following PICU admission since these patients are a vulnerable population at risk for developing psychiatric responses.

Cognitive functioning over 2 years after intracerebral hemorrhage in school-aged children

AIM

Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke.

METHOD

Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed.

RESULTS

PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers.

INTERPRETATION

Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function.

WHAT THIS PAPER ADDS

In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children.

The impact of preterm birth <37 weeks on parents and families: a cross-sectional study in the 2 years after discharge from the neonatal intensive care unit

BACKGROUND

Little is known about the quality of life of parents and families of preterm infants after discharge from the neonatal intensive care unit (NICU). Our aims were (1) to describe the impact of preterm birth on parents and families and (2) and to identify potentially modifiable determinants of parent and family impact.

METHODS

We surveyed 196 parents of preterm infants <24 months corrected age in 3 specialty clinics (82% response rate). Primary outcomes were: (1) the Impact on Family Scale total score; and (2) the Infant Toddler Quality of Life parent emotion and (3) time limitations scores. Potentially modifiable factors were use of community-based services, financial burdens, and health-related social problems. We estimated associations of potentially modifiable factors with outcomes, adjusting for socio-demographic and infant characteristics using linear regression.

RESULTS

Median (inter-quartile range) infant gestational age was 28 (26-31) weeks. Higher Impact on Family scores (indicating worse effects on family functioning) were associated with taking ≥3 unpaid hours/week off from work, increased debt, financial worry, unsafe home environment and social isolation. Lower parent emotion scores (indicating greater impact on the parent) were also associated with social isolation and unpaid time off from work. Lower parent time limitations scores were associated with social isolation, unpaid time off from work, financial worry, and an unsafe home environment. In contrast, higher parent time limitations scores (indicating less impact) were associated with enrollment in early intervention and Medicaid.

CONCLUSIONS

Interventions to reduce social isolation, lessen financial burden, improve home safety, and increase enrollment in early intervention and Medicaid all have the potential to lessen the impact of preterm birth on parents and families.

Neurocognitive Development After Pediatric Heart Surgery

OBJECTIVES

Children with congenital heart disease (CHD) often have neurocognitive deficits, sometimes with a detrimental impact on daily and school functioning. These deficits may increase through childhood. In this study, we investigated whether children with CHD, who underwent heart surgery as infants, show more neurocognitive deficits, especially in the executive functions, as they get older, compared with healthy controls.

METHODS

In this longitudinal follow-up study, 107 children with CHD and 77 healthy control children underwent extensive neurocognitive testing at 4 years of age. Ninety-three percent of the children (100 patients with CHDs and 72 controls) underwent a second neurocognitive testing 3 years later. Intelligence, visual-motor integration (VMI), alertness, motor coordination, executive functions, and psychosocial functioning were assessed.

RESULTS

IQ scores were consistently lower in the CHD group (P < .001); however, the difference of 11.7 IQ points between both groups at follow-up 1 decreased to 7 IQ points at follow-up 2 (P = .003). Inhibition reaction time had improved in both study groups at follow-up 2 (P < .001) and did not differ between both groups from follow-up 1 to follow-up 2 (P = .849). Deficits in VMI, alertness, motor coordination, and psychosocial functioning also did not worsen for patients with CHDs at follow-up 2, compared with healthy controls.

CONCLUSIONS

Children with CHD, who underwent heart surgery as infants, do not show an increase of neurocognitive deficits between the ages of 4 and 7 years, compared with healthy controls. Patients with CHDs keep deficits in intelligence, VMI, and psychosocial functioning, but seem to partially grow out of their deficits.

Family Burden After Out-of-Hospital Cardiac Arrest in Children

OBJECTIVES

To describe family burden among caregivers of children who survived out-of-hospital cardiac arrest and who were at high risk for neurologic disability and examine relationships between family burden, child functioning, and other factors during the first year post arrest.

DESIGN

Secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial.

SETTING

Thirty-six PICUs in the United States and Canada.

PATIENTS

Seventy-seven children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial who had normal prearrest neurologic functioning and were alive 1 year post arrest.

INTERVENTIONS

Family burden was assessed using the Infant Toddler Quality of Life Questionnaire for children less than 5 years old and the Child Health Questionnaire for children 5 years old or older at baseline (reflecting prearrest status), 3 months, and 12 months post arrest. Child functioning was assessed using the Vineland Adaptive Behavior Scale II, the Pediatric Overall Performance Category, and Pediatric Cerebral Performance Category scales and caregiver perception of global functioning.

MEASUREMENTS AND MAIN RESULTS

Fifty-six children (72.7%) were boys, 48 (62.3%) were whites, and 50 (64.9%) were less than 5 years old prior to out-of-hospital cardiac arrest. Family burden at baseline was not significantly different from reference values. Family burden was increased at 3 and 12 months post arrest compared with reference values (p < 0.001). Worse Pediatric Overall Performance Category and Pediatric Cerebral Performance Category, lower adaptive behavior, lower global functioning, and higher family burden all measured 3 months post arrest were associated with higher family burden 12 months post arrest (p < 0.05). Sociodemographics and prearrest child functioning were not associated with family burden 12 months post arrest.

CONCLUSIONS

Families of children who survive out-of-hospital cardiac arrest and have high risk for neurologic disability often experience substantial burden during the first year post arrest. The extent of child dysfunction 3 months post arrest is associated with family burden at 12 months.

Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest

OBJECTIVES

To determine 1) whether early electroencephalographic background features were associated with survival and neurologic outcomes among children resuscitated from cardiac arrest and not treated with therapeutic hypothermia and 2) if addition of electroencephalographic background to commonly used clinical criteria is more predictive of outcome than clinical criteria alone.

DESIGN

Retrospective study.

SETTING

PICU and Cardiac ICUs of a tertiary children's hospital.

PATIENTS

Patients resuscitated from in-hospital or out-of-hospital cardiac arrest who underwent clinically indicated electroencephalographic monitoring and were not treated with therapeutic hypothermia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One-hundred twenty-eight patients underwent electroencephalographic monitoring within 1 day of return of spontaneous circulation. Background category was normal in four subjects (3%), slow-disorganized in 58 subjects (45%), discontinuous-burst suppression in 24 subjects (19%) and attenuated-flat in 42 subjects (33%). Forty-six subjects (36%) had a reactive electroencephalography. Twenty subjects (15%) had a seizure during electroencephalographic monitoring. Absence of reactivity (p < 0.001) and seizures (p = 0.04) were associated with worse electroencephalographic background category. After controlling for covariates, for each incrementally worse background score, the odds of death was 3.63 (95% CI, 2.18-6.0; p < 0.001) and the odds of unfavorable neurologic outcome was 4.38 (95% CI, 2.51-7.17; p = 0.001).

CONCLUSIONS

Worse electroencephalographic background early after resuscitation from both in-hospital and out-of-hospital cardiac arrest is associated with increased odds of death and unfavorable neurologic outcomes at hospital discharge. These electroencephalographic background patterns may be used in addition to clinical criteria to support prognostic decision making.

Serial neuropsychological assessment of an adolescent girl after suffering a sudden out-of-hospital-cardiac-arrest following recreational inhalant use

Sudden out-of-hospital-cardiac-arrest (OHCA) following recreational inhalant use is well documented in the literature. The present case study reports the long-term neuropsychological sequelae of a 14-year-old girl who suffered an OHCA secondary to recreational butane gas inhalation. The patient was assessed on day-13 as an inpatient, and again at 3- and 12-month outpatient follow-ups. Acutely the patient demonstrated significant impairment on tasks associated with verbal and non-verbal memory and executive functioning. Re-testing at 3-months post-acute state suggested improved executive and non-verbal functions while showing continued deficits in verbal memory. At 12-months she was cognitively performing at levels expected for her age. This case is reported for its rarity in successfully being able to track the patient's clinical course from hospital discharge to the successful reintegration back into school and community settings.

Neurobehavioral Outcomes in Children After Out-of-Hospital Cardiac Arrest

OBJECTIVE

This study examined 12-month neurobehavioral outcomes in children who survived out-of-hospital cardiac arrest (OH-CA), were comatose after resuscitation, and were enrolled in a clinical trial to evaluate targeted temperature management to hypothermia (33.0°C) or normothermia (36.8°C) (Therapeutic Hypothermia after Pediatric Cardiac Arrest, Out-of-Hopsital [THAPCA-OH]; NCT00878644).

METHODS

Baseline functioning was assessed by caregiver responses on the Vineland Adaptive Behavior Scales-Second Edition (VABS-II) soon after OH-CA (based on functioning before OH-CA); children with broadly normal baseline functioning (VABS-II ≥70) were included in the THAPCA-OH primary outcome. VABS-II was completed again 12 months later. Then, face-to-face cognitive evaluations were completed. Analyses evaluated changes in VABS-II composite, domain, and subdomain scores and cognitive functioning at follow-up.

RESULTS

Ninety-six of 295 enrolled children were alive at 12 months; 87 of 96 had broadly normal baseline functioning (VABS-II ≥70). Follow-up was obtained on 85/87. Forty-two of 85 had VABS-II ≥70 at 12 months. VABS-II composite, domain, and subdomain scores declined significantly between baseline and 12-month follow-up (P < .001). Declines were greatest in older children. Most children displayed well below average cognitive functioning. Older age at cardiac arrest and higher baseline VABS-II scores were predictive of greater decline in neurobehavioral function. Treatment with hypothermia did not influence neurobehavioral outcomes.

CONCLUSIONS

This is the largest study exploring long-term neurobehavioral outcomes in children surviving OH-CA who were comatose after resuscitation. Results revealed significant neurobehavioral morbidity across multiple functional domains, based both on caregiver reports and performance on objective cognitive measures, in survivors 1 year later.