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Response by Berg et al to Letter Regarding Article, "Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival".

Circulation. 2018;138:2588–2589. DOI: 10.1161/CIRCULATIONAHA.118.037291 2588 Robert A. Berg, MD Vinay M. Nadkarni, MD, MS Robert M. Sutton, MD, MSCE In Response: We and our coauthors thank Dr Guo and colleagues for the kind comments on the rigor of our recently published multicenter observational study establishing the association between diastolic blood pressure (DBP) during pediatric in-hospital cardiopulmonary resuscitation (CPR) and survival.1 In addition, Dr Guo and colleagues note that propofol and opioids may influence outcomes from circulatory arrest in the special circumstance of planned cardiopulmonary bypass, a clinical situation that differs in many ways from the unplanned cardiac arrests among critically ill children in our study. They wonder whether the dose and timing of propofol or opioids in the intensive care unit affected the patient outcomes, and they specifically ask if we can reanalyze our data to address this issue. Unfortunately, information on the dose and timing of opioids and propofol in our study is not available, thereby precluding such analyses. For several reasons, it is unlikely that our findings are attributable to propofol or opioid effects rather than DBPs during CPR. First, our findings are consistent with numerous preclinical laboratory investigations in multiple species1–4 and adult clinical data5 demonstrating that DBP and the resultant coronary perfusion pressure during CPR are the main determinants of successful resuscitation. Second, the outcomes support our specific a priori hypothesis that DBP during CPR ≥25 mm Hg in infants <1 year of age and ≥30 mm Hg in children ≥1 years of age would be associated with an increased likelihood of return of spontaneous circulation, survival to hospital discharge, and survival to hospital discharge with a favorable neurological outcome.1 Third, propofol use is limited in pediatric intensive care units in the United States because of the US Food and Drug Administration black box warnings. Therefore, all study sites avoid the use of propofol for the maintenance of sedation in these critically ill children. Although we do not have available data to definitively refute or support the contention of Dr Guo and colleagues, the preponderance of evidence supports our hypothesis that DBP during pediatric in-hospital CPR is associated with survival. Specifically, when mean DBP was maintained ≥25 mm Hg during the early minutes of CPR in infants <1 year of age and ≥30 mm Hg in children ≥1 years of age, patients were 70% more likely to survive to hospital discharge and 60% more likely to survive to hospital discharge with favorable neurological outcome compared with patients not attaining these mean DBP thresholds.1