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Hypoxemia, Hypercapnia After Cardiac Arrest Reduce Survival To Discharge Rate In Children
March 27, 2025
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Key takeaways:Pediatric patients that received chest compressions for cardiac arrest faced a reduced likelihood for survival to hospital discharge if they had hypoxemia or hypercapnia in the first 24 hours after arrest, according to study results.
These findings were published in Annals of the American Thoracic Society.
Pediatric patients that received chest compressions for cardiac arrest faced a reduced likelihood for survival to hospital discharge if they had hypoxemia or hypercapnia in the first 24 hours after arrest. Image: Adobe Stock"Our findings support guideline recommendations to target normoxemia after [return of spontaneous circulation] and limit exposure to severe hypercapnia and hypocapnia," Aisha H. Frazier, MD, division chief of cardiac critical care at Nemours Children's Health, and colleagues wrote.
In a prospective, multicenter, observational study, Frazier and colleagues assessed 284 pediatric patients (42% aged younger than 1 year; 53.5% male; 46.1% white) that received chest compressions for cardiac arrest in an ICU to find out the link between survival to hospital discharge and hypoxemia (arterial oxygen tension/pressure [PaO2] less than 60 mm Hg) in the first 24 hours after cardiac arrest, as well as hyperoxemia (PaO2 200 mm Hg or higher) in the first 24 hours after cardiac arrest.
Researchers also evaluated the link between survival and post-arrest hypocapnia (arterial carbon dioxide tension/pressure [PaCO2] less than 30 mm Hg) and post-arrest hypercapnia (PaCO2 50 mm Hg or higher).
To be included, patients had to have a corrected gestational age of 37 weeks or more.
Based on oxygenation, 80 patients had hypoxemia, 87 had hyperoxemia, 32 had both and 85 had normoxemia (PaO2 60 to 199 mm Hg).
Between those with hypoxemia and those with normoxemia, researchers observed a reduced likelihood for survival to hospital discharge following adjustment for illness category, age and CPR length among patients with hypoxemia (adjusted relative risk [aRR] = 0.71; 95% CI, 0.58-0.87).
In contrast, no difference in survival was found when comparing patients with hyperoxemia with patients with normoxemia (aRR = 1; 95% CI, 0.87-1.15).
Both of these findings held true when switching from rate of survival to hospital discharge to rate of survival with favorable neurological outcome.
Based on carbon dioxide, 29 patients had hypocapnia, 147 had hypercapnia, 30 had both and 78 had normocapnia (PaCO2 30 to 49 mm Hg).
Those with hypocapnia had similar rates of survival to hospital discharge to those with normocapnia (aRR = 0.91; 95% CI, 0.74-1.12), but this was not the case between patients with hypercapnia and patients with normocapnia. Researchers found a reduced likelihood for survival among those with hypercapnia vs. Normocapnia (aRR = 0.74; 95% CI, 0.64-0.84).
The above findings again held true when switching from rate of survival to hospital discharge to rate of survival with favorable neurological outcome.
Notably, the probability of survival went down to a greater degree when a patient had both post-arrest hypoxemia and hypercapnia vs. Hypoxemia or hypercapnia alone (40% vs. 19% to 20%).
"Analyses of patients who received CPR for a pulseless rhythm demonstrated associations that were similar to those of the overall group that included patients with bradycardia and poor perfusion," Frazier and colleagues wrote.
Perspective Back to Top This prospective observational study conducted across 18 pediatric ICUs from 2016 to 2021 gives strong evidence on the importance of maintaining normoxemia and normocapnia within the first 24 hours after return of spontaneous circulation to improve survival and neurological outcomes. The study showed hypoxemia and hypercapnia to be associated with 29% and 26% lower survival rates, emphasizing the critical need to optimize ventilation and oxygenation after cardiac arrest. The normocapnia group demonstrated superior outcomes with a 91% survival rate and 85% achieving favorable neurological outcomes compared with 65% and 61% in the hypercapnia group and only 76% survival in the hypocapnia group. These findings also clarify that extreme deviations in blood gas levels, particularly increase in carbon dioxide, have poor results. It is surprising to see 31.5% of enrolled patients were excluded due to lack of arterial blood gases (ABG) in the first 24 hours after cardiac arrest, which shows the practical challenges in a clinical setting. This puts forward the value for alternate methods, such as end-tidal carbon dioxide (CO2) monitoring, a noninvasive method that provides continuous real time data and is especially valuable during resuscitation and post-arrest care. Even though ABG remains the gold standard, end-tidal CO2 can bridge the gap in monitoring and enhance adherence to normoxemia and normocapnia when frequent arterial blood gas is not practical. The study also highlights the difficulty in meeting guideline targets with only 30% of patients achieving normoxemia and 27% maintaining normocapnia within the first 24 hours after return of spontaneous circulation. This shows the importance of continuous CO2 monitoring and custom ventilation strategies to optimize management. This study has the potential to significantly influence clinical guidelines. Incorporating these findings into clinical practice can help physicians optimize lung protective ventilation strategies, reduce the risk of hypoxemia and hypercapnia and improve survival and neurological outcomes. Further research should focus on long-term neurological outcomes after cardiac arrest and refining ventilation targets to improve maintenance of normoxemia and normocapnia. Vijay Sam Nethala, MD Resident Physician, Internal Medicine, Northwest Medical Center TucsonDisclosures: Nethala reports no relevant financial disclosures.
Sources/DisclosuresCollapse Disclosures: Frazier reports no relevant financial disclosures. Please see the study for all other authors' relevant financial disclosures.Add topic to email alerts
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Manoj Bharathiraja Death: What Can Cause A Cardiac Arrest After Bypass Surgery?
A cardiac arrest happens when your heart stops beating or beats so fast that it stops pumping blood
Manoj Bharatiraja died of cardiac arrest just a few days after he underwent a bypass surgery. The 48-year-old actor and director returned home last week from the hospital, according to news reports.
Bharatiraja, who was last seen in Prime Video's Snakes and Ladders, made his debut in 1999 with Taj Mahal.
According to experts, a cardiac arrest happens when your heart stops beating or beats so fast that it stops pumping blood. During cardiac arrest, you may suddenly collapse and become unresponsive. Doctors say the symptoms start without warning, and that is why it is known as sudden cardiac arrest.
This life-threatening condition can become fatal if you are not given immediate treatment.
During cardiac arrest, also known as cardiopulmonary arrest, your heart stops pumping blood, and within minutes your organs and whole body get a big risk of death because they must constantly receive oxygen. Your blood delivers that oxygen. Emergency treatment includes cardiopulmonary resuscitation, or CPR, and defibrillation, which can help keep enough oxygen in your lungs and get it to your brain until an electric shock restores a normal heart rhythm. CPR and defibrillators may save your life.
Doctors say cardiac arrest can happen within days of coronary artery bypass surgery, even though it is uncommon, with an incidence of around 0.7–2.9 per cent. And so, it is important to make a prompt diagnosis and treatment, which are crucial for improving survival rates.
Cardiac arrest after the surgery can be attributed to many complications:
Infection
Doctors say the wounds in your chest and arm or leg can become infected after a coronary artery bypass graft. It can also cause infection in your lungs or the inside of the chest after having a coronary artery bypass graft.
Most infections that develop after the procedure can usually be treated successfully with antibiotic tablets or injections.
Irregular heartbeat
Many people who have a coronary artery bypass graft develop atrial fibrillation—a condition that can cause an irregular and often abnormally fast heart rate. However, doctors believe it is not as serious and can be treated easily if diagnosed well in time.
Brain-related issues
Many people who recently underwent bypass surgery also experience memory issues, finding it difficult to concentrate on things like reading books or a newspaper. It usually improves in the months following the surgery but can sometimes be permanent.
There's also a risk of serious problems affecting the brain during or after a coronary artery bypass graft, such as a stroke.
Following a coronary artery bypass graft, there are several factors that increase your risk of developing complications.
Age
Your risk of developing complications after surgery increases as you get older, as there are many other serious long-term health conditions that spike the possibility.
Being a woman
Women develop coronary artery disease later than men, and so, it may lead to a higher risk of having complications.
Emergency surgery
An emergency surgery is always riskier because doctors do not get much time to plan the surgery, and the heart can be seriously damaged from a heart attack.
Having more than 2 vessels grafted
According to experts, the more complex the operation, the greater the chance of having complications.
Obesity
If you are obese or overweight, the surgeon will have to make a deeper cut to gain access to your heart, which has a higher risk of becoming infected.
Get Latest News Live on Times Now along with Breaking News and Top Headlines from Health and around the world.ROSC Explained: What It Means In Cardiac Arrest And CPR
Learn what goes into return of spontaneous circulation and why it's significantMarch 20, 2025 04:03 PM •
Timeliness is critical to achieving return of spontaneous circulation and improving survival outcomes. The faster good-quality resuscitation begins, the better the victim's chances at ROSC and a positive result.
In emergency medical response scenarios, ROSC – the return of spontaneous circulation – refers to the restoration of a palpable pulse and effective circulation following cardiac arrest and cardiopulmonary resuscitation (CPR). With the heart beating on its own again, ROSC is an important medical milestone indicating successful resuscitation efforts.
Achieving ROSC does not guarantee full medical recovery – hospitalization and intensive postresuscitation care are still needed – but is a positive step toward stabilization and survival.
What are key steps to getting ROSC in a cardiac arrest patient?Timeliness is critical to achieving return of spontaneous circulation and improving survival outcomes. The faster good-quality resuscitation begins, the better the victim's chances at ROSC and a positive result.
An effective medical response in cardiac arrest scenarios begins with early recognition and quick action. Bystanders should call 911 to summon help and begin CPR immediately. More than 90% of emergency call centers in the U.S. Have at least some telephone CPR (T-CPR) training, so call-takers and dispatchers can often provide medical guidance to help inexperienced rescuers work toward return of spontaneous circulation.
Speed matters in obtaining ROSC: With ventricular fibrillation (VF), the most treatable kind of cardiac arrest, survival odds drop by 7%–10% a minute until CPR and other medical interventions begin.
Effective chest compressions (100–120 a minute, with a depth of at least two inches) are essential to keep blood flowing to vital organs and achieving ROSC. Defibrillation within 3–5 minutes of collapse improves the chances of ROSC, as does timely airway management and administration of key Advanced Cardiac Life Support (ACLS) medications like epinephrine and amiodarone.
What are ways to know if ROSC has happened?Key indicators of return of spontaneous circulation include a detectable pulse (usually checked at a major artery, such as the carotid or femoral); measurable blood pressure; spontaneous breathing; a skin tone that improves from blue-grey to more natural tones; and restoration of an organized heart rhythm on electrocardiogram.
What resuscitation actions come after ROSC?Once return of spontaneous circulation is achieved, the focus of medical treatment shifts to stabilization, preventing rearrest and minimizing brain injury.
Post-ROSC medical priorities include optimizing hemodynamics to maintain sufficient circulation to vital organs; targeted temperature management for unconscious patients, meaning cooling the body to 32°–36°C for 24–48 hours to reduce oxygen demand and inflammation; oxygenation and ventilation support; and ECG/cardiac monitoring. If a myocardial infarction is suspected, immediate cardiac catheterization is recommended.
Managing arrhythmias and preventing rearrest involves identifying and treating an arrest's underlying causes. A popular mnemonic for this involves five H's and five T's. The H's stand for common metabolic and physiologic causes of arrest and include:
The T's represent common structural and toxic causes and include:
Medications may also help prevent recurrent VF. Other post-ROSC medical measures can include neurological monitoring, infection prevention and managing blood glucose.
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