Blood pressure targets after return of circulation following cardiac arrest in infants and children: a systematic review and meta-analysis

Aim

To systematically review the literature examining optimal blood pressure targets following in-hospital or out-of-hospital cardiac arrest in infants and children. (PROSPERO ID CRD42023483865).

Methods

We searched Medline, EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) for randomised controlled trials and non-randomised studies for all years up to March 19, 2025. Risk of bias and certainty of evidence was assessed using Newcastle-Ottawa and GRADE. Critically important outcomes survival to hospital discharge and survival with favourable neurological outcome.

Results

We identified 11 observational studies, including 2855 cardiac arrest events in infants and child. No randomised clinical trials were found. Patients exposed to a systolic blood pressure (SBP) greater than 5th percentile for age within six hours of return of circulation, compared to less than 5th percentile had a higher risk of survival to hospital discharge (RR 1.41; 95 % CI [1.2–1.6]; P = 0.01) and better survival with favourable neurological outcome at hospital discharge (RR1.25; 95 % CI [1.11–1.64]; P = 0.01). Exposure to a SBP greater than 10th centile for age was also associated with increased survival at hospital discharge and survival with favourable neurological outcome at hospital discharge (RR 1.21; 95 % CI [1.00–1.33}; P < 0.01 and RR 1.22; 95 % CI [1.10–1.35}; P < 0.01 and RR respectively). Mean Blood Pressure targets (>10th percentile) and diastolic blood pressure targets (>50th percentile) were also reported and associated with improved critical outcomes. However, variation in time points, blood pressure definitions and outcome assessment limited pooled analysis. Risk of bias was low, and the certainty of evidence was very low.

Conclusion

Early hypotension after return of circulation post cardiac arrest is associated with worse outcomes in infants and children after cardiac arrest. Patients exposed to systolic or mean arterial blood pressure targets greater than fifth and tenth percentile for age have improved risk of survival to hospital discharge and survival with favourable neurologic outcomes at hospital discharge.