Elsevier

Heart, Lung and Circulation

Volume 28, Issue 12, December 2019, Pages 1904-1912
Heart, Lung and Circulation

Original Article
Changing Risk of In-Hospital Cardiac Arrest in Children Following Cardiac Surgery in Victoria, Australia, 2007–2016

https://doi.org/10.1016/j.hlc.2018.11.003Get rights and content

Background

Reported incidence of in hospital cardiac arrest (IHCA) after paediatric cardiac surgery varies between 3–4% in high income countries and this risk may have changed over time. We sought to examine this trend in detail.

Methods

A retrospective observational study of 3,781 children who underwent 4,938 cardiac surgeries between 1 January 2007 and 31 December 2016 in a tertiary children’s hospital. IHCA was defined as cessation of cardiac mechanical activity requiring cardiac massage for ≥1 minute. Surgical complexity was categorised using risk adjusted congenital heart surgery (RACHS-1) category. Poisson regression was used to analyse trends for every two-year period.

Results

There were a total of 211 (4.3%) IHCA events after surgery. These patients were younger, more likely to have had a premature birth, have a chromosomal or genetic syndrome association and have a high surgical complexity. Overall, there was a 52% reduction in IHCA rate over 10 years: reducing from 5.4 /100 surgeries in 2007–08 to 2.6/100 surgeries in 2015–16 (p-trend = <0.001). The reduction was mainly seen in low-to-moderate risk categories (RACHS-1 categories 1–4) and not in high risk categories (RACHS-1 category 5–6). Children in high risk categories were 13.6 times more likely to experience an IHCA (compared to low risk categories). Overall hospital mortality for children suffering IHCA decreased from 42.5/100 patients in 2007–08 to 11.1/100 patients in 2015–16 (p-trend = 0.037).

Conclusions

The IHCA rate following cardiac surgery has more than halved over the last decade; children who experience IHCA also have lower mortality than in previous years. High risk procedures still have a substantial rate of IHCA and efforts are needed to minimise the burden further in this population.

Introduction

Recent single centre studies and registry reports suggest that in-hospital cardiac arrest (IHCA) occurs in 3% to 4% of children following cardiac surgery [1], [2], [3]. This rate is much higher in high risk groups, such as children undergoing complex operations and those who have had a previous cardiac arrest, with IHCA rates reaching up to 20% in these children [1], [3], [4], [5]. While the majority of IHCA following cardiac surgery occurs in the highly monitored intensive care setting, outcomes are still poor with hospital mortality approaching 30–50% and poor neurological outcomes in up to 25% of survivors [4], [6], [7].

Collected reviews from several investigators over the last 15 years suggest that both the incidence of, and survival following, IHCA after cardiac surgery is improving. Incidence has fallen to 3–4% from 6–10% and survival has risen to 70% from 19% [1], [3], [4], [8], [9], [10], [11]. These estimates, however, come from different regions, with studies conducted at different time periods and utilising differing definitions of IHCA. Genuine changes in IHCA rates after cardiac surgery over time can only be inferred from such reports. In addition, there has been limited discussion about factors that might have had an impact on changes in IHCA rate. Monitoring IHCA trends and understanding factors that may have influenced these trends is a high priority for quality improvement. In this report, we analyse changes in the rates of IHCA and mortality in children experiencing IHCA following cardiac surgery, and discuss factors which may have influenced these changes over a 10-year period.

Section snippets

Study Population and Setting

The study was undertaken at the Royal Children’s Hospital, Melbourne (RCH), Australia. The institution is a referral centre for specialised paediatric cardiac services and performs all major paediatric cardiac surgeries for children from the Australian states of Victoria, Tasmania, South Australia, Northern Territory and Western Australia, encompassing a population of approximately eight million. The Paediatric Intensive Care Unit (PICU) is a 30-bed multidisciplinary unit with a dedicated

Study Population and Baseline Characteristics

We analysed data from 3,781 children with congenital heart disease who underwent 4,938 surgeries during a 10-year period. A total of 382 episodes of IHCA were identified. After 171 exclusions (Figure 1), there were 211 IHCA events following surgery that met inclusion criteria. Children who had IHCA were younger, more likely to be female, to have had a preterm birth and to have an underlying chromosomal or genetic syndrome association (Table 1). Children who experienced IHCA suffered

Major Findings

In this analysis involving 3,781 children who underwent 4,938 cardiac surgeries, we noted a 52% reduction in the rate of IHCA over a 10-year period. The IHCA rate based on the most recent period (2015–16) was 2.6%. However, this decrease was only seen in low to moderate risk surgeries (RACHS-1 categories 1–4), with no change in high risk surgeries. Children undergoing high risk surgeries were 13.6 times more likely to experience IHCA and were less likely to survive to hospital discharge

Conclusions

In conclusion, data from this single, large centre study shows that there was a 52% reduction in the rate of IHCA in children following cardiac surgery over the 10-year study period. This reduction was likely possible for many reasons, including personnel and organisational factors and evolving developments in the care of children requiring cardiac surgery. The fall in IHCA rate, along with a fall in mortality among patients experiencing an IHCA, is likely to have contributed to reductions in

Conflicts of Interest

No potential conflicts of interest exist for any of the authors.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

We would like to thank the PICU data research team and staff in the Paediatric Intensive Care Unit and Cardiac services at the Royal Children’s Hospital, Melbourne. Dr Siva Namachivayam is supported by a Health Professional Scholarship (ID: 101603) from the National Heart Foundation of Australia.

References (28)

  • J.A. Alten et al.

    Epidemiology and outcomes of cardiac arrest in pediatric cardiac ICUs

    Pediatr Crit Care Med

    (2017)
  • P. Gupta et al.

    Epidemiology and outcomes after in-hospital cardiac arrest after pediatric cardiac surgery

    Ann Thorac Surg

    (2014)
  • S.P. Namachivayam et al.

    Survival status and functional outcome of children who required prolonged intensive care after cardiac surgery

    J Thorac Cardiovasc Surg

    (2016)
  • R.I. Matos et al.

    Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests

    Circulation

    (2013)
  • Cited by (0)

    View full text