Neuropsychological outcomes of children 1 year after pediatric cardiac arrest

Slomine BS, Silverstein FS, Christensen JR, Page K, Holubkov R, Dean JM, Moler FW. Neuropsychological Outcomes of Children 1 Year After Pediatric Cardiac Arrest: Secondary Analysis of 2 Randomized Clinical Trials. JAMA Neurol. 2018 Dec 1;75(12):1502-1510.

Abstract

IMPORTANCE:

Little is known about neuropsychological outcomes of children who survived pediatric cardiac arrest (CA).

OBJECTIVE:

To describe the neuropsychological outcomes of CA survivors enrolled in the Therapeutic Hypothermia After Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) and Out-of-Hospital (THAPCA-OH) trials and compare the results with the primary outcome measure for these trials.

DESIGN, SETTING, AND PARTICIPANTS:

Secondary analysis of 222 CA survivors aged 1 to 18 years who received chest compressions for 2 minutes or more, remained comatose and required mechanical ventilation after return of circulation, and were enrolled in targeted temperature-management trials from 41 pediatric intensive care units. Data were collected from September 3, 2009, to February 3, 2016, and analyzed from March 10, 2017, to April 20, 2018.

MAIN OUTCOMES AND MEASURES:

The Vineland Adaptive Behavior Scales, Second Edition (VABS-II), a standardized measure of neurobehavioral functioning based on caregiver report (age-corrected mean [SD] scores = 100 [15]), was used to evaluate pre-CA functioning within 24 hours after enrollment; VABS-II<70 indicated significant developmental delays; VABS-II and neuropsychological testing were completed 1 year after CA. Neuropsychological testing included the Mullen Scales of Early Learning (Mullen) for children younger than 6 years and the Wechsler Abbreviated Scale of Intelligence (WASI) and neuropsychological measures of attention, memory, processing speed, and executive functioning for older children.

RESULTS:

Of 160 participants who completed neuropsychological testing, 96 (60.0%) were male; the median (interquartile range [IQR]) age was 2.5 years (1.3-6.1 years). Ninety-six (60.0%) were white, 41 (25.6%) were black, and 23 (14.4%) were of other/unknown race; 343 (21.2%) were Hispanic or Latino; 119 (74.4%) were non-Hispanic or Latino; and 7 (4.4%) were of unknown ethnicity. One hundred fourteen participants (71.2%) were classified as having favorable outcomes (VABS-II ≥70). Impairments (>2 SD below the mean for age) across neuropsychological measures ranged from 7% to 61%. Correlations between global cognitive and VABS-II scores were strong for younger children (Mullen, r = 0.69-0.87) but moderate for older children (r = 0.21-0.54 for the WASI). Of 111 children with favorable outcomes on VABS-II, 25.2% had global cognitive impairment and 30 of 35 older children (85.7%) had selective neuropsychological deficits.

CONCLUSIONS AND RELEVANCE:

In this prospectively evaluated cohort of pediatric CA survivors who were initially comatose, although 71.2% were classified as having favorable outcomes, significant neuropsychological deficits were identified in pediatric CA survivors who were classified as having favorable outcomes. The findings provide clinicians with a greater understanding of the spectrum of neuropsychological outcomes of pediatric CA survivors and the complex relationship between standardized caregiver-reported functional outcome measures incorporated in clinical trials and performance-based neuropsychological assessments.

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Researchers performed secondary analysis of cardiac arrest (CA) survivors enrolled in the Therapeutic Hypothermia After Pediatric Cardiac Arrest In-Hospital (THAPCA-IH) and Out-of-Hospital (THAPCA-OH) trials, to describe their neuropsychological outcomes. They also compare the results with the primary outcome measure for these trials. Although 71.2% of the survivors had favorable caregiver-rated outcomes 1 year later, the survivors displayed significant performance-based neuropsychological deficits across measures. 

Methods

Participants of this secondary analysis comprised 222 CA survivors, aged 1 to 18 years who received chest compressions for 2 minutes or more, remained comatose and required mechanical ventilation after return of circulation.

These participants were enrolled in targeted temperature-management trials from 41 pediatric intensive care units.

Collection of data was done from September 3, 2009, to February 3, 2016, and analysis was done from March 10, 2017, to April 20, 2018.

Pre-CA functioning within 24 hours after enrollment was evaluated using the Vineland Adaptive Behavior Scales, Second Edition (VABS-II), a standardized measure of neurobehavioral functioning based on caregiver report (age-corrected mean [SD] scores = 100 [15]); VABS-II<70 indicated significant developmental delays; completion of VABS-II and neuropsychological testing was done 1 year after CA.

The Mullen Scales of Early Learning (Mullen) was used for neuropsychological testing in children younger than 6 years; neuropsychological testing in older children was done determining the Wechsler Abbreviated Scale of Intelligence (WASI) and neuropsychological measures of attention, memory, processing speed, and executive functioning.

Results

Neuropsychological testing was completed by 160 participants [96 (60.0%) were male; the median (interquartile range [IQR]) age was 2.5 years (1.3-6.1 years)].

Of these, 96 (60.0%) were white, 41 (25.6%) were black, and 23 (14.4%) were of other/unknown race; 343 (21.2%) were Hispanic or Latino; 119 (74.4%) were non-Hispanic or Latino; and 7 (4.4%) were of unknown ethnicity.

Researchers classified 114 participants (71.2%) as having favorable outcomes (VABS-II ≥70).

The participants displayed impairments (>2 SD below the mean for age) ranging from 7% to 61% across neuropsychological measures.

Younger children displayed strong correlations (Mullen, r = 0.69-0.87) between global cognitive and VABS-II scores but older children showed moderate correlations (r = 0.21-0.54 for the WASI).

Global cognitive impairment was evident in 25.2% and selective neuropsychological deficits were noted in 30 of 35 older children (85.7%) among the 111 children with favorable outcomes on VABS-II.

https://www.mdlinx.com/journal-summaries/cardiology-child-development-critical-care-medicine/2018/12/12/7551094?spec=neurology