PToR criteria with high specificity may predict termination of resuscitation among pediatric OHCA patients: Study

Prehospital termination of resuscitation (ToR) guidelines are employed to assess medical futility in adults experiencing out-of-hospital cardiac arrest (OHCA), but there is a lack of sufficient evidence regarding their application in pediatric patients. Recent study aimed to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic out-of-hospital cardiac arrest (OHCA) patients. The researchers analyzed a retrospective cohort of pediatric OHCA patients within the CARES database over a 10-year period from 2013-2022. The primary outcome was non-survival to hospital discharge, and the secondary outcome was non-survival to hospital discharge or survival to hospital discharge with unfavorable neurologic status. The researchers fit logistic regressions with Least Absolute Shrinkage and Selection Operator (LASSO) to select predictor variables and estimate predictive test characteristics.

Dataset Overview and Findings

The full dataset included 22,697 children, with 2,326 (11.0%) surviving to hospital discharge, and 1,894 (8.9%) surviving to hospital discharge with favorable neurologic status. The derived PToR rule for non-survival to hospital discharge consisted of four criteria: 1) Unwitnessed arrest; 2) Absence of cardiac electrical activity (asystole); 3) Arrest not due to drowning or electrocution; and 4) No sustained ROSC. This rule demonstrated a specificity of 99.1% and a positive predictive value (PPV) of 99.8% in the test dataset.

Expanded PToR Rule

The PToR rule for non-survival to hospital discharge or survival with unfavorable neurologic status consisted of five criteria: 1) Unwitnessed arrest; 2) Absence of cardiac electrical activity (asystole); 3) Arrest not due to drowning or electrocution; 4) No sustained ROSC; and 5) No bystander CPR. This rule also demonstrated a specificity of 99.1% and a PPV of 99.8% in the test dataset.

Conclusions and Future Directions

The researchers found that these PToR criteria had similar performance across different age groups (infants, children, and adolescents) as well as across gender and racial/ethnic groups. The authors concluded that these PToR criteria with high specificity and positive predictive value may help inform termination of resuscitation considerations in the prehospital setting for pediatric OHCA patients. They emphasized that further prospective and validation studies are still necessary to define the appropriateness and applicability of these PToR criteria for routine use.

Key Points

1. The study aimed to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic out-of-hospital cardiac arrest (OHCA) patients.

2. The primary outcome was non-survival to hospital discharge, and the secondary outcome was non-survival to hospital discharge or survival to hospital discharge with unfavorable neurologic status.

3. The derived PToR rule for non-survival to hospital discharge consisted of four criteria: 1) Unwitnessed arrest; 2) Absence of cardiac electrical activity (asystole); 3) Arrest not due to drowning or electrocution; and 4) No sustained ROSC. This rule demonstrated a specificity of 99.1% and a positive predictive value (PPV) of 99.8% in the test dataset.

4. The PToR rule for non-survival to hospital discharge or survival with unfavorable neurologic status consisted of five criteria: 1) Unwitnessed arrest; 2) Absence of cardiac electrical activity (asystole); 3) Arrest not due to drowning or electrocution; 4) No sustained ROSC; and 5) No bystander CPR. This rule also demonstrated a specificity of 99.1% and a PPV of 99.8% in the test dataset.

5. The researchers found that these PToR criteria had similar performance across different age groups (infants, children, and adolescents) as well as across gender and racial/ethnic groups.

6. The authors concluded that these PToR criteria with high specificity and positive predictive value may help inform termination of resuscitation considerations in the prehospital setting for pediatric OHCA patients, but further prospective and validation studies are still necessary to define the appropriateness and applicability of these PToR criteria for routine use.

Reference –

Pranav Shetty et al. (2024). Derivation Of A Clinical Decision Rule For Termination Of Resuscitation In Non-Traumatic Pediatric Out-Of-Hospital Cardiac Arrest.. *Resuscitation*, . https://doi.org/10.1016/j.resuscitation.2024.110400.