Diastolic Blood Pressure During Pediatric In-Hospital Cardiac Arrest: Trends and Associations With Outcomes

OBJECTIVES: Pediatric resuscitation guidelines support using diastolic blood pressure (DBP) as a marker of cardiopulmonary resuscitation (CPR) quality. Thresholds of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children were derived from data limited to the first 10 minutes of CPR, regardless of event duration. We aimed to describe DBP trajectories throughout in-hospital cardiac arrest and evaluate associations between DBP thresholds and return of spontaneous circulation (ROSC) in prolonged CPR (≥ 10 min). DESIGN: Single-center retrospective cohort study (2017-2023). SETTING: PICU and CICU. PATIENTS: Pediatric IHCA with invasive arterial BP monitoring. SETTING AND PATIENTS: Pediatric IHCAs with invasive arterial BP monitoring. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Events with greater than or equal to 1 minute of evaluable DBP data were included in trend analyses; those with greater than or equal to 1 minute of evaluable DBP data after 10 minutes of CPR were included in prolonged CPR analyses. Linear and mixed-effects regression assessed DBP trends; univariate logistic regression evaluated associations between DBP thresholds and ROSC. Among 118 events (median age 0.4 yr; 69% with congenital heart disease), DBP rose early and plateaued above guideline thresholds. Early ROSC was associated with higher average DBP (p = 0.02) and steeper early DBP rise (p < 0.001). In 46 prolonged events, 80% had mean DBP above guideline thresholds. In prolonged CPR, an upward DBP trend was associated with ROSC (p < 0.001). In prolonged CPR, meeting current DBP thresholds was not significantly associated with ROSC, but achieving higher thresholds (≥ 30 mm Hg in infants and ≥ 35 mm Hg in children) later in CPR was associated with ROSC (odds ratio 7.14; 95% CI, 1.58-51.35; p = 0.009). CONCLUSIONS: DBP can be sustained above current thresholds during prolonged CPR. Larger cohort studies are needed to determine if higher, patient-specific, and time-dependent DBP targets are required to achieve ROSC in prolonged CPR.