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Induction and maintenance of therapeutic hypothermia after pediatric cardiac arrest: Efficacy of a surface cooling protocol*

Topjian, Alexis MD; Hutchins, Larissa RN, MSN, CCRN; DiLiberto, Mary Ann BS, RN; Abend, Nicholas S. MD; Ichord, Rebecca MD; Helfaer, Mark MD; Berg, Robert A. MD; Nadkarni, Vinay MD

Pediatric Critical Care Medicine: May 2011 - Volume 12 - Issue 3 - p e127-e135
doi: 10.1097/PCC.0b013e3181e28717
Online Clinical Investigations

Objective: To assess the feasibility, effectiveness, side effects, and adverse events associated with a standardized surface cooling protocol. Induced therapeutic hypothermia after pediatric cardiac arrest is an important intervention.

Design: Prospective intervention trial.

Setting: Urban, tertiary care children's hospital.

Patients: Twelve pediatric cardiac arrest survivors.

Interventions: Standardized surface cooling protocol.

Measurements and Main Results: Patients (age: median, 1.5 yrs; interquartile range, 0.5–6.25; cardiopulmonary resuscitation duration: median, 18 mins; interquartile range, 10–45) were cooled by a standard surface cooling protocol for rapid induction and maintenance of goal rectal temperature (T) 32°C–34°C for 24 hrs, with prospectively defined rescue protocols. Side effects and clinical interventions were recorded. Median time to rectal T ≤34°C was 1.5 (1, 1.5) hrs from cooling initiation and 6 (5, 6.5) hrs from arrest. T was documented every 30 mins. Maintenance target T 32°C–34°C was attained in 78% (414 of 531) of measurements, overshoot hypothermia <32°C in 15% (81 of 531), and overshoot hyperthermia >34°C in 7% (36 of 531). Mean bias between rectal vs. esophageal T was −0.42°C (95% confidence interval, −0.49 to −0.35), and between rectal and bladder T was 0.16°C (95% confidence interval, 0.11–0.22). Side effects observed included: hypokalemia <3.0 mEq/L in 67% of patients and bradycardia <2% for age in 58%. There were no episodes of bleeding or ventricular tachyarrhythmia that required treatment. Six (50%) of 12 patients survived to discharge.

Conclusions: A standard surface cooling protocol achieved rapid induction of hypothermia after pediatric cardiac arrest. During maintenance of hypothermia, 78% of measures were within target T 32°C–34°C. Commonly employed temperature sites (esophageal, rectal, and bladder) were similar. Overshoot hypothermia and associated side effects were common, but there were no serious adverse events attributable to induced therapeutic hypothermia in this case series. Surface cooling protocols to induce and maintain therapeutic hypothermia after pediatric cardiac arrest are potentially feasible.

From the Departments of Anesthesia, Critical Care, and Pediatrics (AT, MAD, MH, RAB, VN), Nursing (LH), and Neurology (NSA, RI), The Children's Hospital of Philadelphia (CHOP), University of Pennsylvania School of Medicine, Philadelphia, PA.

This study was supported, in part, by CTRC grant UL1-RR-024134 and the Endowed Chair of Pediatric Critical Care Medicine.

Drs. Topjian, Ichord, and Nadkarni received funding from the National Heart, Lung and Blood Institute for their roles as investigators in the Therapeutic Hypothermia After Cardiac Arrest study. The remaining authors have not disclosed any potential conflicts of interest.

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©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies