Therapeutic hypothermia after paediatric cardiac arrest: Pooled randomized controlled trials

A Bayesian Interpretation of a Pediatric Cardiac Arrest Trial (THAPCA-OH)

Bayesian Reanalysis of Pediatric Cardiac Arrest TrialOnly 7,000 children experience out-of-hospital cardiac arrest annually in the United States, and thus it is difficult to conduct large trials. This study presents a way to leverage all existing data by conducting a Bayesian reanalysis of the THAPCA-OH (Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital) trial.

Targeted temperature management at 36°C is a risk factor for ventilator-associated pneumonia

BACKGROUND

In contrast to the adult population, limited information is currently available on risk factors for ventilator-associated pneumonia (VAP) in children. Therapeutic hypothermia has been identified as a risk factor for the early onset of VAP in adults; however, the relationship between VAP and normothermia remains unclear. The present study investigated risk factors for VAP in children, with a focus on the deleterious effects of therapeutic normothermia on VAP.

METHODS

We retrospectively investigated the clinical characteristics of children treated with mechanical ventilation for more than 48 h and analyzed risk factors for VAP. The endpoint was the onset of VAP by the seventh day after the initiation of mechanical ventilation.

RESULTS

Among the 288 patients enrolled, seven (2.4%) developed VAP. No significant differences were observed in clinical backgrounds between the VAP and non-VAP groups. A univariate analysis identified target temperature management (TTM) at 36°C (p < 0.0001) and methylprednisolone (mPSL) pulse therapy (p = 0.02) as risk factors for VAP. An analysis of the time to the onset of VAP by the Kaplan-Meier plot and log-rank test revealed a significantly higher incidence of VAP in the TTM group (p < 0.0001) and mPSL pulse group (p = 0.001).

CONCLUSION

TTM at 36°C and mPSL pulse therapy may be risk factors for VAP in the pediatric population.

Evolution of the Collaborative Pediatric Critical Care Research Network

The Collaborative Pediatric Critical Care Research Network (CPCCRN) was established by the Eunice Kennedy Shriver National Institute of Child Health and Human Development in May 2005 to develop an infrastructure for collaborative clinical trials and meaningful descriptive studies in pediatric critical care. This article describes the history of CPCCRN, discusses its financial and organizational structure, illustrates how funds were efficiently used to carry out studies, and describes CPCCRN public use datasets and future directions, concluding with the development of the PeRsonalizEd Immunomodulation in PediatriC SepsIS-InducEd MODS study.

State-of-the-art management of the acutely unwell child

Children make up around one-fifth of all emergency department visits in the USA and UK, with an increasing trend of emergency admissions requiring intensive care. Anaesthetists play a vital role in the management of paediatric emergencies contributing to stabilisation, emergency anaesthesia, transfers and non-technical skills that optimise team performance. From neonates to adolescents, paediatric patients have diverse physiology and present with a range of congenital and acquired pathologies that often differ from the adult population. With increasing centralisation of paediatric services, staff outside these centres have less exposure to caring for children, yet are often the first responders in managing these high stakes situations. Staying abreast of the latest evidence for managing complex low frequency emergencies is a challenge. This review focuses on recent evidence and pertinent clinical updates within the field. The challenges of maintaining skills and training are explored as well as novel advancements in care.

Efficacy of Targeted Temperature Management after Pediatric Cardiac Arrest: A Meta-Analysis of 2002 Patients

Cardiac arrest (CA) is associated with high mortality and poor life quality. Targeted temperature management (TTM) or therapeutic hypothermia is a therapy increasing the survival of adult patients after CA. The study aim was to assess the feasibility of therapeutic hypothermia after pediatric CA. We performed a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the use of TTM after pediatric CA. The primary outcome was survival to hospital discharge or 30-day survival. Secondary outcomes included a one-year survival rate, survival with a Vineland adaptive behavior scale (VABS-II) score ≥ 70, and occurrence of adverse events. Ten articles (n = 2002 patients) were included, comparing TTM patients (n = 638) with controls (n = 1364). In a fixed-effects meta-analysis, survival to hospital discharge in the TTM group was 49.7%, which was higher than in the non-TTM group (43.5%; odds ratio, OR = 1.22; 95% confidence interval, CI: 1.00, 1.50; p = 0.06). There were no differences in the one-year survival rate or the occurrence of adverse events between the TTM and non-TTM groups. Altogether, the use of TTM was associated with a higher survival to hospital discharge; however, it did not significantly increase the annual survival. Additional high-quality prospective studies are necessary to confer additional TTM benefits.

Care Does Not Stop Following ROSC: A Quality Improvement Approach to Postcardiac Arrest Care

Supplemental Digital Content is available in the text.

Pediatric cardiac arrests carry significant morbidity and mortality. With increasing rates of return of spontaneous circulation, it is vital to optimize recovery conditions to decrease morbidity.

Necessity of early and continuous monitoring for possible infectious complications in children undergoing therapeutic hypothermia

AIM

Since therapeutic hypothermia (TH) is known for its inhibitory effects on leucocyte migration and cytokine synthesis, our aim was to underline the necessity of early monitoring for potential immunomodulatory risks.

METHODS

Using a 13-year retrospective case-control study at the paediatric intensive care unit (PICU) of the Medical University in Vienna, all newborn infants and children receiving TH were screened and compared with a diagnosis-matched control group undergoing conventional normothermic treatment (NT). TH was accomplished by using a non-invasive cooling device. Target temperature was 32-34°C. Children with evident infections, a medical history of an immunodeficiency or undergoing immunosuppressive therapy, were excluded.

RESULTS

During the observational period, 108 patients were screened, 27 of which underwent TH. Culture-proven infections occurred in 22% of the TH group compared with 4% of the normothermic controls (P = .1). From the second day following PICU admission, median C-reactive protein (CRP) values were higher in the TH group (day two P = .002, day three P = .0002, day six P = .008).

CONCLUSION

Children undergoing TH showed earlier and higher increases in CRP levels when compared to normothermic controls. These data underline the necessity of early and continuous monitoring for possible infectious complications.

Hypothermia: Impact on plasticity following brain injury

Therapeutic hypothermia (TH) is a potent neuroprotectant against multiple forms of brain injury, but in some cases, prolonged cooling is needed. Such cooling protocols raise the risk that TH will directly or indirectly impact neuroplasticity, such as after global and focal cerebral ischemia or traumatic brain injury. TH, depending on the depth and duration, has the potential to broadly affect brain plasticity, especially given the spatial, temporal, and mechanistic overlap with the injury processes that cooling is used to treat. Here, we review the current experimental and clinical evidence to evaluate whether application of TH has any adverse or positive effects on postinjury plasticity. The limited available data suggest that mild TH does not appear to have any deleterious effect on neuroplasticity; however, we emphasize the need for additional high-quality preclinical and clinical work in this area.

Paediatric targeted temperature management post cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

The International Liaison Committee on Resuscitation prioritized the need to update the review on the use of targeted temperature management (TTM) in paediatric post cardiac arrest care. In this meta-analysis, the effectiveness of TTM at 32-36 °C was compared with no target or a different target for comatose children who achieve a return of sustained circulation after cardiac arrest.

METHODS

Electronic databases were searched from inception to December 13, 2018. Randomized controlled trials and non-randomized studies with a comparator group that evaluated TTM in children were included. Pairs of independent reviewers extracted the demographic and outcome data, appraised risk of bias, and assessed GRADE certainty of effects. A random effects meta-analysis was undertaken where possible.

RESULTS

Twelve studies involving 2060 patients were included. Two randomized controlled trials provided the evidence that TTM at 32-34 °C compared with a target at 36-37.5 °C did not statistically improve long-term good neurobehavioural survival (risk ratio: 1.15; 95% CI: 0.69-1.93), long-term survival (RR: 1.14; 95% CI: 0.93-1.39), or short-term survival (risk ratio: 1.14; 95% CI: 0.96-1.36). TTM at 32-34 °C did not show statistically increased risks of infection, recurrent cardiac arrest, serious bleeding, or arrhythmias. A novel analysis suggests that another small RCT might provide enough evidence to show benefit for TTM in out-of-hospital cardiac arrest.

CONCLUSION

There is currently inconclusive evidence to either support or refute the use of TTM at 32-34 °C for comatose children who achieve return of sustained circulation after cardiac arrest. Future trials should focus on children with out-of-hospital cardiac arrest.