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Doctoral Thesis
DOI
https://doi.org/10.11606/T.5.2022.tde-26042023-125225
Document
Author
Full name
Tânia Miyuki Shimoda Sakano
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2022
Supervisor
Committee
Reis, Amélia Gorete Afonso da Costa (President)
Cesar, Regina Grigolli
Couto, Thomaz Bittencourt
Leone, Clea Rodrigues
Title in Portuguese
Fatores prognósticos da ressuscitação cardiopulmonar pediátrica no hospital
Keywords in Portuguese
Epidemiologia
Parada cardíaca
Pediatria
Prognóstico
Reanimação cardiopulmonar
Sobrevida
Abstract in Portuguese
Introdução: A sobrevida da ressuscitação cardiopulmonar (RCP) pediátrica hospitalar vem aumentando nos países desenvolvidos, mas os estudos em países em desenvolvimento são escassos. Além disso, os fatores prognósticos associados à sobrevida e desfecho neurológico não estão esclarecidos. Métodos:Trata-se de um estudo observacional baseado em um registro prospectivo de RCP no estilo Utstein em um hospital de alta complexidade. O objetico primário foi analisar os fatores associados à sobrevida e ao desfecho neurológico após 180 dias. O objetivo secundário foi comparar a sobrevida e o desfecho neurológico com o estudo anterior realizado no mesmo hospital há 20 anos. Foram incluídos pacientes < 18 anos submetidos à RCP de janeiro de 2015 a dezembro de 2020. A função neurológica foi avaliada nos períodos pré-RCP, na alta e após 180 dias através da análise de prontuário e entrevistas com familiares e profissionais de saúde envolvidos no cuidado e registradas de acordo com a Pediatric Cerebral Performance Categories (PCPC). Para análise estatística, utilizou-se o teste qui-quadrado ou o teste exato de Fisher para as variáveis categóricas. O modelo de regressão logística univariada e multivariada foi aplicado à análise de fatores associados à sobrevida na alta e após 180 dias. Resultados: Entre os 323 pacientes submetidos à RCP, 108 (33,4%) apresentaram sobrevida à alta hospitalar e 93 (28,8%) após 180 dias. Condições crônicas complexas (CCC) foi encontrada em 311 pacientes (96,3%). Os fatores associados à menor sobrevida na alta na análise multivariada foram a doença hepática (OR:0.060, 95%IC 0,007-0,510, p=0,010), choque como causa precipitante da RCP (OR:0.183, IC95%0,069-0,486, p=0,001), infusão de droga vasoativa pré-RCP (OR:0.145, 95%IC 0.065-0,325, p<0,001), uso de bicarbonato durante a RCP (OR:0.318, IC95% 0,130-0,780, p=0,012) e duração prolongada da RCP (OR:0.070, IC 95% 0,014-0,344, p=0,001). Os mesmos fatores permaneceram associados à menor sobrevida após 180 dias. Disfunção neurológica (PCPC 3) foi observada em 30,8% das crianças. O prognóstico neurológico foi favorável em 79,7% na alta e 76,1% após 180 dias. Os fatores associados ao prognóstico neurológico favorável após 180 dias na análise multivariada foram: idade > 1 ano (OR: 23.894, IC 95% 2.735-208.735, p=0,004) e não administração de drogas vasoativas pré-RCP (OR:4.518, IC95%1.116-18.291, p=0,035). O desfecho neurológico desfavorável ocorreu em 5,5% (N=5) entre a alta hospitalar e 180 dias. Comparando-se o presente estudo com o anteriormente realizado no mesmo hospital e publicado em 2002, houve redução na incidência de RCP (21,4/1000 internações no estudo anterior versus 5.1-8.2/1000 internações no presente). Também houve aumento da sobrevida à alta (16,3 vs 33,7%) e após 180 dias (15,5 vs 29,1%), respectivamente para o estudo de 2002 e atual. Conclusão: Os fatores associados à menor sobrevida da RCP em pacientes pediátricos em hospital de alta complexidade foram: doença hepática, choque como causa precipitante da PCR, infusão de drogas vasoativas pré-RCP, uso de bicarbonato durante a RCP e RCP prolongada. O prognóstico neurológico foi favorável na maioria dos sobreviventes. A idade > 1 ano e a não administração de drogas vasoativas pré-RCP estiveram associadas a um prognóstico neurológico favorável. A sobrevida após PCR hospitalar em crianças com CCC melhorou significativamente ao longo do tempo
Title in English
Prognostic factors of pediatric in-hospital cardiopulmonary resuscitation
Keywords in English
Cardiac arrest
Cardiopulmonary resuscitation
Epidemiology
Pediatric
Prognosis
Survival
Abstract in English
Background: In-hospital pediatric cardiopulmonary resuscitation (CPR) survival has been improving in developed countries, but studies in developing countries are scarce. Additionally, prognostic factors associated with survival and neurological outcome are unclear. Methods: This is an observational study based on an Utstein style prospective registry of in-hospital CPR in a high-complexity hospital. The primary outcome was to analyze the factors associated with survival and neurological outcome after 180 days. The secondary outcome was to compare survival and neurological outcome with a previous study in the same hospital published 20 years earlier. Patients <18 years old submitted to CPR from January 2015 to December 2020 were included. Pre-CPR, at discharge and after 180 days neurological status was identified through analysis of records and interviews with family members and health professionals involved in care and recorded according to the Pediatric Cerebral Performance Category (PCPC). For statistical analysis, the Chi-square test or Fisher's exact test for categorical variables was used. The univariate and multivariate logistic regression model was applied to the analysis of factors associated with survival at discharge and after 180 days. Results: A total of 323 patients were submitted to CPR, 108 (33.4%) survived to hospital discharge and 93 (28.8%) were alive after 180 days. Complex chronic conditions (CCC) were found in 311 patients (96.3%). Factors associated with lower survival at discharge in multivariate analysis were liver disease (OR:0.060, 95%CI 0.007-0.510, p=0.010), shock as precipitating cause of CPR (OR:0.183, 95%CI 0.069-0.486, p=0.001), vasoactive drug infusion pre-CPR (OR:0.145, 95%CI 0.065-0.325, p<0.001), use of bicarbonate during CPR (OR:0.318, 95%CI 0.130-0.780, p=0.012) and prolonged resuscitation time (OR:0.070, 95%CI 0.014-0.344, p=0.001). The same factors remained associated with lower survival after 180 days. Before CPR, 30.8% of the children presented neurological dysfunction (PCPC 3). Good neurological prognosis was found in 79.7% at discharge and 76.1% after 180 days. In multivariate analysis, factors associated with favorable neurological prognosis at discharge and after 180 days were age > 1 year (OR: 23.894, 95%CI 2.735-208.735, p=0.004) and non-administration of vasoactive drugs pre-CPR (OR:4.518, 95%CI 1.116-18.291, p=0.035). Poor neurological outcome occurred in 5.5% (N=5) between hospital discharge and 180 days. Comparing the current study with the one previously conducted at the same hospital and published in 2002, there was a reduction in the incidence of CPR (21.4/1000 admissions in the previous study vs 5.1-8.2/1000 admissions in the current one). There was also an increase in survival at discharge (16.3 vs 33.7%) and after 180 days (15.5 vs 29.1%), respectively for the 2002 study and current one. Conclusion: Factors associated with lower CPR survival in pediatric patients in a high-complexity hospital were liver disease, shock as a precipitating cause of arrest, pre-CPR vasoactive drug infusion, bicarbonate use during CPR, and prolonged CPR. Neurological prognosis was favorable in most survivors. Age >1 year and non-administration of vasoactive drugs pre-CPR were associated with good neurological prognosis. Survival after in-hospital cardiac arrest in children with CCC has improved significantly over time
 
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Publishing Date
2023-05-05
 
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