Outcomes of in-hospital cardiac arrest in paediatric oncology patients

**Introduction-**Cardiac page or code blue is an intensive care service, which once activated, mobilizes a dedicated team to the site of cardiac arrest with all the equipment required for resuscitation. Successful resuscitation requires early recognition, immediate action by the parent team till ICU team arrives, high quality advanced cardiac life support and cardiopulmonary resuscitation (CPR) and efficient transport to the ICU. The underlying pathology plays the most important role in determining the outcome of the child. This is the reason that many a times the revival at site does not transcend to survival at hospital discharge. This may reflect ill-sustained revival of organ function and irreversible damage setting in before, during or post cardiac arrest. To address cardiac page episodes and associated poor survival, we as a team, started Mortality Morbidity meetings (M&M) between paediatric oncologists and intensivists to review all deaths, 2 years back. These meetings are known to enhance professional learning, assure safe clinical practices, identify areas of improvement, and monitor quality of hospital care. The focus was on systematic process change and we ensured a non-judgmental environment. There are certain considerations unique to cancer setting. Sepsis is the biggest cause of morbidity and mortality in these immunocompromised children. Cancer being a specialized branch, patients travel from distant places causing delay in presentation. Frequent cardiac page is received from the casualty. Parents should be educated regarding warning signs. Lack of ‘do not resuscitate’ orders may allow CPR in unwarranted situations. Survival to in hospital cardiac arrest is 46% at discharge as per a recent systematic review. National registry of cardiopulmonary resuscitation in United States suggests 27% survival to discharge, but only 15.7% with good neurological outcome.Outcomes in hematology/oncology children are much inferior. We conducted M& M meetings monthly to enable in-depth discussion of such cases. It is beneficial to know different perspectives of wider audience, encourages a culture of openness, issues are identified, and actions specified. Overall, this facilitates change in practice. We believe, these meetings have had a positive impact due to emphasis on early recognition, implementation of early warning scores in wards, early transfer, and better coordination between the two teams. We work on lines of guidelines published by Clinical Excellence Commission (2020) for the same. Many children with event survival, die before hospital discharge. Early recognition, implementation of trigger tools or warning scores in wards, timely transfer of clinically deteriorating patients, rapid response teams may help improve outcomes. This is a quality improvement audit to see our outcome of cardiac page practices.

**Methodology-**We are a tertiary cancer hospital in western India. We aim to retrospectively study our electronic medical records of two years (November 2021 to October 2023), pertaining to cardiac page of children (0-18 years) with cancer received by our ICU team. This will be a descriptive review. These do not include cardiac arrest of patients already admitted in the ICU.

**Statistical Analysis-**In this retrospective cohort study, our objective is to comprehensively analyze the outcomes of in-hospital cardiac arrest in pediatric oncology patients. Through meticulous data collection from medical records, we will capture critical information encompassing patient demographics, oncological disease specifics, cardiac arrest details (including causes), resuscitation interventions, and ultimate outcomes such as survival and neurological status. The statistical analysis plan encompasses descriptive statistics, survival analysis using Kaplan-Meier curves and log-rank tests, multivariate analyses employing Cox proportional hazards regression to adjust for confounders, stratified and subgroup analyses, as well as sensitivity analyses to ensure the robustness of the findings. Categorical variables (e.g., gender, oncological stage)will be represented in a form of frequencies and percentages and continuous variables (e.g., age, duration of ICU stay) will be represented as mean and standard deviations.