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.

Effect of forced-air warming system in prevention of postoperative hypothermia in elderly patients: A Prospective controlled trial

BACKGROUND

Postoperative hypothermia in elderly patients is a well-known serious complication as it impairs wound healing, induces coagulopathy, increases the risk of blood loss, enhances oxygen consumption, and precipitates cardiac arrhythmias. We conducted this randomized controlled trial to evaluate the effect of a forced-air warming system on rewarming elderly patients undergoing total knee or hip arthroplasty.

METHODS

We recruited 243 elderly patients undergoing total knee or hip arthroplasty between May and December 2016. They were divided into three groups according to a computer-generated randomization table: group C (n = 78, rewarmed with only a regular blanket), group F1 (n = 82, rewarmed with a forced-air warming system set at 38°C), and group F2 (n = 83, rewarmed with a forced-air warming system set at 42°C). The nasopharyngeal temperature was recorded every 5 min for the first half hour, then every 10 min up to the end of the PACU (postanesthesia care unit) stay. The primary outcome was the rewarming time. The rewarming rate, increase in nasopharyngeal temperature (compared to the start of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded.

RESULTS

No significant differences were found among the three groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the elderly patients in groups C and F1, both the heart rate and mean arterial pressure of those in group F2 were significantly increased 20 min after arrival at the PACU (P < .05). Patients in group F2 had the shortest rewarming time (35.89 ± 6.45 min, P < .001), highest rewarming efficiency (0.028 ± 0.001°C/min, P < .001), and fastest increased nasopharyngeal temperature among the three groups. Moreover, the elderly patients in group F2 had lower incidences of arrhythmia and shivering (P < .05).

CONCLUSIONS

The use of a forced-air warming system set at 42°C was shown to be the most effective way of rewarming elderly patients with postoperative hypothermia.

Effect of an electric blanket plus a forced-air warming system for children with postoperative hypothermia: A randomized controlled trial

BACKGROUND

Postoperative hypothermia in children in postanesthesia care unit (PACU) is a well-known serious complication as it increases the risk of blood loss, wound infections, and cardiac arrhythmias. We conducted this prospective randomized controlled trial to evaluate the effect of an electric blanket plus a forced-air warming system on rewarming in children with postoperative hypothermia.

METHODS

We recruited 346 children (aged < 3 years) who were admitted to a PACU after surgery and diagnosed with hypothermia between March and August 2016. They were randomly divided into 3 groups: group C (n = 108, rewarmed with only a regular blanket), group E (n = 123, rewarmed with a regular blanket plus an electric blanket), and group EF (n = 115, rewarmed with an electric blanket plus a forced-air warming system). From the beginning of rewarming, the rectal temperature was recorded every 5 minutes for the first half hour, then every 10 minutes up to when the patient left the PACU. The primary outcome was the rewarming time of children (from the beginning of rewarming to recovery of normothermia). The rewarming rate, increase in temperature (compared with the beginning of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded.

RESULTS

There were no significant differences among the 3 groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the children in groups C and E, both the heart rate and mean arterial pressure of those in group EF were significantly increased after 10 minutes of arriving at the PACU (P < .05). Children in the EF group had the shortest rewarming time (35.61 ± 16.45 minutes, P < .001) and highest rewarming efficiency (0.028 ± 0.001 °C/min, P < .001), while there was no evidence of a difference in increased rectal temperature among the 3 groups. Children in the EF group had lower incidences of arrhythmia, shivering, nausea, and vomiting (P < .05).

CONCLUSION

The combination of an electric blanket and a forced-air warming system was shown to be an effective rewarming method for children with postoperative hypothermia.

Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial

BACKGROUND

On the basis of mixed results from previous trials, we assessed whether therapeutic hypothermia for 48-72 h with slow rewarming improved mortality in children after brain injury.

METHODS

In this phase 3, multicenter, multinational, randomised controlled trial, we included patients with severe traumatic brain injury who were younger than 18 years and could be enrolled within 6 h of injury. We used a computer-generated randomisation sequence to randomly allocate patients (1:1; stratified by site and age [<6 years, 6-15 years, 16-17 years]) to either hypothermia (rapidly cooled to 32-33°C for 48-72 h, then rewarmed by 0·5-1·0°C every 12-24 h) or normothermia (maintained at 36·5-37·5°C). The primary outcome was mortality at 3 months, assessed by intention-to-treat analysis; secondary outcomes were global function at 3 months after injury using the Glasgow outcome scale (GOS) and the GOS-extended pediatrics, and the occurrence of serious adverse events. Investigators assessing outcomes were masked to treatment. This trial is registered with ClinicalTrials.gov, number NCT00222742.

FINDINGS

The study was terminated early for futility after an interim data analysis on data for 77 patients (enrolled between Nov 1, 2007, and Feb 28, 2011): 39 in the hypothermia group and 38 in the normothermia group. We detected no between-group difference in mortality 3 months after injury (6 [15%] of 39 patients in the hypothermia group vs two [5%] of 38 patients in the normothermia group; p=0·15). Poor outcomes did not differ between groups (in the hypothermia group, 16 [42%] patients had a poor outcome by GOS and 18 [47%] had a poor outcome by GOS-extended paediatrics; in the normothermia group, 16 [42%] patients had a poor outcome by GOS and 19 [51%] of 37 patients had a poor outcome by GOS-extended paediatrics). We recorded no between-group differences in the occurrence of adverse events or serious adverse events.

INTERPRETATION

Hypothermia for 48 h with slow rewarming does not reduce mortality of improve global functional outcome after paediatric severe traumatic brain injury.

FUNDING

National Institute of Neurological Disorders and Stroke and National Institutes of Health.

Anaesthesia for neurosurgical procedures in paediatric patients

Recent advances in neurosurgery, neuromonitoring and neurointensive care have dramatically improved the outcome in patients affected by surgical lesions of central nervous system (CNS). Although most of these techniques were applied first in the adult population, paediatric patients present a set of inherent challenges because of their developing and maturing neurological and physiological status, apart from the CNS disease process. To provide optimal neuroanaesthesia care, the anaesthesiologist must have the knowledge of basic neurophysiology of developing brain and effects of various drugs on cerebral haemodynamics apart from the specialised training on paediatric neuroanaesthesia. This article highlights on the perioperative management of paediatric neurosurgical patients.