Prognostic utility of the revised post-cardiac arrest syndrome for therapeutic hypothermia score in pediatric patients with post-cardiac arrest syndrome

The accurate prognosis of post-cardiac arrest syndrome (PCAS) is critical for guiding intensive care and family communication. The revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score incorporates six readily available clinical variables and has shown promise in children. However, prior validations involved older children. We aimed to externally validate rCAST scores in a cohort of infants and young children. We retrospectively examined patients with PCAS (with pre-arrest pediatric cerebral performance category scores of 1-3 and receiving targeted temperature management) admitted to a pediatric intensive care unit (PICU) between December 2016 and March 2024. Patients were stratified into low-, moderate-, and high-severity groups based on their rCAST scores. The primary outcome was neurological status at PICU discharge. Among 5456 PICU admissions, 75 were included (median age, 17 months [interquartile range: 4-72]; 68% without pre-existing conditions). Favorable neurological outcomes occurred in 28% of patients overall, with 76% in the low (n = 17) and 73% in the moderate (n = 11) groups, but none in the high group (n = 47). The overall in-hospital mortality rate was 60%: 6% in the low group and 87% in the high group (P < 0.001). The rCAST score showed good discrimination for both unfavorable neurological outcome (area under the curve [AUC], 0.947; 95% confidence interval [CI], 0.894-1.000) and mortality (AUC, 0.857; 95% CI, 0.750-0.964). The rCAST score demonstrated good discriminative ability for neurological outcomes in infants and young children with PCAS. However, unfavorable outcomes in some patients with low scores warrant caution in clinical decision-making.