(718) Progression to Pulselessness Among Children Receiving CPR for Bradycardia With Poor Perfusion

Introduction: Half of pediatric in-hospital CPR is started for non-pulseless Bradycardia with Poor Perfusion (BPP). While clinical BPP events are reported to have higher survival rates than pulseless arrests, previous studies have been limited in their ability to validate true pulselessness. We aimed to use physiologic waveforms to characterize BPP CPR events and determine the incidence and time course of progression of BPP to pulselessness.

Methods: Secondary analysis of index pediatric CPR events from the 18 ICUs of the ICU-RESUS trial. Events 2 min with initial rhythm of BPP and interpretable concurrent invasive arterial blood pressure (BP) monitoring were included. Arterial BP waveforms were reviewed during CPR interruptions, with pulselessness defined as systolic BP < 40 mmHg for infants and < 50 mmHg for older children. Each 30-second CPR epoch was classified as: 1. ongoing CPR for BPP; 2. ongoing CPR with pulselessness; 3. return of spontaneous circulation (ROSC); 4. transition to extracorporeal support (ECPR); or 5. death. Fisher’s exact and Kruskal-Wallis tests compared outcomes between events with: 1. only BPP; 2. BPP progressing to pulselessness; and 3. BPP progressing to pulselessness with 1 return to BPP.

Results: Among 186 included BPP events, 63% progressed to pulselessness and 63% achieved ROSC. Of 117 events with pulselessness: 48% were pulseless by 1 min, 73% by 2 min, and 85% by 3 min. Cross-sectional analysis among patients continuing to receive CPR: of 163 patients at min 2, 50% had BPP, 45% were pulseless, 5% had pulselessness with return to BPP; of 111 patients at min 5, 28% had BPP, 54% were pulseless, 18% had pulselessness with return to BPP; of 70 patients at min 10, 21% of patients had BPP, 59% were pulseless, 20% had pulselessness with return to BPP. Sustained ROSC was highest in events with only BPP (83.8%) compared to BPP progressing to pulselessness (43%) and BPP with pulselessness and 1 return to BPP (62%) (p < 0.001).

Conclusions: Most children receiving CPR for BPP develop pulselessness, mostly within 2 minutes. Patients with any pulselessness (validated by arterial BP waveform criteria) are less likely to achieve ROSC. These data reiterate the importance of providing CPR for BPP and provide additional context for studies of this population.