Over 15,000 children experience in-hospital cardiac arrest (IHCA) annually in the U.S., with high mortality and common morbidity among survivors, despite advances in cardiopulmonary resuscitation (CPR) and resuscitation guidelines. IHCA in children is heterogeneous, often stemming from underlying diseases like sepsis, a frequent cause of critical illness. Studies report that 14–34% of paediatric IHCA cases involve preexisting sepsis, which is linked to worse outcomes due to both prearrest illness severity and sepsis-related physiologic disturbances that impair resuscitation and recovery. However, detailed studies focusing specifically on sepsis-related IHCAs are limited.
A recent study used data from the ICU-Resuscitation Project (ICU-RESUS) clinical trial to better characterise paediatric IHCA cases involving sepsis. The goals were to assess how prearrest sepsis affects survival and neurologic outcomes and to examine its association with blood pressure during and after CPR. The researchers hypothesised that sepsis would correlate with worse neurologic outcomes, higher illness severity, and lower intraarrest and postarrest blood pressures.
The ICU-RESUS trial was conducted across 18 ICUs at 10 U.S. children’s hospitals, evaluating physiology-directed CPR training and postcardiac arrest debriefing. It included children ≤18 years (≥37 weeks corrected gestational age) who received CPR in a participating ICU. The study examined the impact of prearrest sepsis on outcomes in paediatric IHCA. The primary exposure was a diagnosis of sepsis before arrest, with primary outcomes being survival to hospital discharge with favourable neurologic function and average diastolic blood pressure (DBP) during CPR.
Among 1,129 children with IHCA, 184 (16.3%) had prearrest sepsis. These patients had more comorbidities, greater illness severity, higher vasoactive support, longer CPR durations, and more frequent use of epinephrine and sodium bicarbonate. They were significantly less likely to survive with favourable neurologic outcome (28.3% vs. 58.4%), with an adjusted relative risk of 0.54. Despite these differences, intraarrest DBPs were similar between groups. Postarrest, children with sepsis had higher vasoactive needs, more frequent hypotension, and higher mortality within 48 hours.
This study found that 16.3% of children who experienced IHCA in ICUs across major children’s hospitals had prearrest sepsis. These children had significantly worse outcomes, including lower rates of survival with favourable neurologic outcomes, 24-hour survival, and survival to discharge, compared to those without sepsis.
Despite the hypothesis that sepsis-related vasodilation would result in lower intraarrest blood pressures (BPs), there were no significant differences in intraarrest diastolic BPs or ETCO₂ levels between groups, suggesting that CPR quality was comparable. However, children with sepsis required longer CPR durations, more frequent epinephrine and bicarbonate use, and had more severe illness both before and after arrest. Postarrest, they experienced greater hypotension, higher vasoactive drug needs, and higher mortality, particularly within the first 24 hours.
The study suggests that poor outcomes in sepsis patients are not solely due to inadequate intraarrest perfusion, but also due to persistent physiologic instability and possibly unmeasured metabolic and inflammatory dysfunctions. Even when prearrest severity was similar, children with sepsis still had worse outcomes, implying that current haemodynamic goals may be insufficient for this population.
Early post-arrest management appears critical. Sepsis patients had higher vasoactive needs at 6 hours but more frequent hypotension later, indicating possible lapses in maintaining strict haemodynamic targets. Only 1 of 23 children with sepsis who received extracorporeal CPR (ECPR) survived with good neurologic outcome, raising concerns about ECPR effectiveness in this subgroup.
Overall, children with prearrest sepsis who experienced IHCA in the ICU had significantly worse survival and neurologic outcomes compared to those without sepsis. These differences persisted despite similar rates of achieving intraarrest blood pressure targets, indicating that high-quality CPR alone may be insufficient and that alternative therapeutic strategies are needed for this high-risk group.
Source: Critical Care Medicine
Image Credit: iStock
References:
Morgan RW, Reeder RW, Carcillo JA et al. (2025) Outcomes, Characteristics, and Physiology of In-Hospital Cardiac Arrest in Children With Sepsis. Critical Care Medicine. 53(8):p e1529-e1541.
