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Effectiveness of Two Targeted Temperature Management Methods After Pediatric Postcardiac Arrest

A Multicenter International Study*

Yunge, Mauricio, MD1; Cordero, Jaime, MD1; Martinez, Daniela, MD, PhD1; Bustos, Raul, MD2,3; Wegner, Adriana, MD4; Castro, Magdalena, RN5; Arrau, Lorena, RN1; Diaz, Betsy, RN1; Dalmazzo, Roberto, MD1; Hickmann, Lilian, MD2; Lapadula, Michelangelo, MD6; Yañez, Leticia, MD6; Roque, Jorge, MD7; Cecchetti, Corrado, MD8; Bravo, Pablo, MD9; Cruces, Pablo, MD10; Acuña, Carlos, MD11; Oyaguez, Pablo, MD12; Miras, Alicia, MD12; Morales, Antonio, MD13; Nieto, Manuel, MD14; Lopez, Yolanda, MD14; Morales, Gonzalo, MD15; Drago, Michele, MD16; Nalegach, Maria Elisa, MD16; Sepulveda, German, MD17; Menchaca, Amanda, MD18; Jerez, Florencia, MD19; Glasinovic, Maritza, MD20; Mallea, Fernando, MD20; Lopez-Herce, Jesus, MD21

Pediatric Critical Care Medicine: February 2019 - Volume 20 - Issue 2 - p e77–e82
doi: 10.1097/PCC.0000000000001813
Online Clinical Investigations

Objectives: It is currently recommended that after return of spontaneous circulation following cardiac arrest, fever should be prevented using TTM through a servo-controlled system. This technology is not yet available in many global settings, where manual physical measures without servo-control is the only option. Our aim was to compare feasibility, safety and quality assurance of servo-controlled system versus no servo-controlled system cooling, TTM protocols for cooling, maintenance and rewarming following return of spontaneous circulation after cardiac arrest in children.

Design: Prospective, multicenter, nonrandomized, study.

Setting: PICUs of 20 hospitals in South America, Spain, and Italy, 2012–2014.

Patients: Under 18 years old with a cardiac arrest longer than 2 minutes, in coma and surviving to PICU admission requiring mechanical ventilation were included.

Methods: TTM to 32–34°C was performed by prospectively designed protocol across 20 centers, with either servo-controlled system or no servo-controlled system methods, depending on servo-controlled system availability. We analyzed clinical data, cardiac arrest, temperature, mechanical ventilation duration, length of hospitalization, complications, survival, and neurologic outcomes at 6 months. Primary outcome: feasibility, safety and quality assurance of the cooling technique and secondary outcome: survival and Pediatric Cerebral Performance Category at 6 months.

Measurements and Main Results: Seventy patients were recruited, 51 of 70 TTM (72.8%) with servo-controlled system. TTM induction, maintenance, and rewarming were feasible in both groups. Servo-controlled system was more effective than no servo-controlled system in maintaining TTM (69 vs 60%; p = 0.004). Servo-controlled system had fewer temperatures above 38.1°C during the 5 days of TTM (0.1% vs 2.9%; p < 0.001). No differences in mortality, complications, length of mechanical ventilation and of stay, or neurologic sequelae were found between the two groups.

Conclusions: TTM protocol (for cooling, maintenance and rewarming) following return of spontaneous circulation after cardiac arrest in children was feasible and safe with both servo-controlled system and no servo-controlled system techniques. Achieving, maintaining, and rewarming within protocol targets were more effective with servo-controlled system versus no servo-controlled system techniques.

1PICU, Clinica Las Condes, Santiago, Chile.

2PICU, Hospital Regional Concepcion, Chile.

3PICU, Sanatorio Aleman, Concepcion, Chile.

4PICU, Hospital Sotero del Rio, Santiago, Chile.

5Academic Direction, Clinica Las Condes, Santiago, Chile.

6PICU, Clinica Santa Maria, Santiago, Chile.

7PICU, Clinica Alemana, Santiago, Chile.

8Department of Acceptance Emergency, Pediatric Children’s Hospital Gesu, IRCCS, Rome, Italy.

9PICU, Hospital San Juan de Dios, Santiago, Chile.

10PICU, Hospital Padre Hurtado, Santiago, Chile.

11PICU, Hospital Calvo Mackenna, Santiago, Chile.

12PICU, Hospital de Burgos, España.

13PICU, Hospital Regional Universitario Carlos Haya, Malaga, Spain.

14PICU, Hospital Universitario de Cruces, Vizcaya, País Vasco, Spain.

15PICU, Hospital Roberto del Río, Santiago, Chile.

16PICU, Hospital Exequiel Gonzalez Cortes, Santiago, Chile.

17PICU, Hospital de Punta Arenas, Chile.

18PICU, Hospital Pereyra Rossel, Montevideo, Uruguay.

19PICU, Hospital de Tucumán, Argentina.

20PICU, Clínica Davila, Santiago, Chile.

21PICU, Hospital General Universitario Gregorio Marañon, Universidad Complutense de Madrid, Maternal and Child Health and Development Network (Red SAMID), Madrid, Spain.

*See also p. 206.

All authors have made significant contributions to all of the following: the conception and design of the study, the acquisition, analysis and interpretation of data and critically reviewing the article. We have developed the Ibero-American and Italian Group of Post Cardiac Arrest Hypothermia in Pediatrics.

Supported, in part, by Academic Direction, Clinica Las Condes.

The authors have disclosed that they do not have any potential conflicts of interest.

The Ethics Committees of the participating centers approved the study and patients, parents or caregivers signed informed consent. Data were recorded on a website and in a database created for the study and was confidentially and anonymously handled.

For information regarding this article, E-mail: myunge@clinicalascondes.cl, myungeb@gmail.com

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies