Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest in Children | Journal Scan

Study Questions:

What is the impact of therapeutic hypothermia on neurobehavioral outcome and survival after cardiac arrest in children, as compared with maintenance of normothermia?

Methods:

THAPCA-OH was a multicenter, randomized clinical trial. Within 6 hours of return of circulation, comatose patients >2 days of age and <18 years of age were randomized to either therapeutic hypothermia (target temperature, 33ºC) or therapeutic normothermia (target temperature, 36.8ºC).The primary outcome measure was survival at 12 months, with a score on the Vineland Adaptive Behavior Scales, second edition (VABS-II), of 70 or higher. The VABS-II scale ranges from 20 to 160 (mean score 100), with higher scores indicating better function.

Results:

A total of 295 patients were randomized, of which 260 had data that could be evaluated and had a baseline VABS-II score of ≥70. There was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86-2.76; p = 0.14). The change in VABS-II score from baseline to 12 months post-arrest was not significantly different (p = 0.13), and the 1-year survival was similar (38% in the hypothermia group and 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93-1.79; p = 0.13). There were no differences in incidences of infection, serious arrhythmias, use of blood products, and 28-day mortality.

Conclusions:

In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with good functional outcome at 1 year.

Perspective:

Since the publication of trials suggesting benefit of therapeutic hypothermia in adults with cardiac arrest due to ventricular arrhythmias, there has been great interest in identifying additional groups that might benefit. This study failed to demonstrate a significant benefit of therapeutic hypothermia in pediatric patients after out-of-hospital arrest. There did appear to be a trend toward benefit, so it is possible that a larger trial may have achieved statistical significance. One reason for the difference between this and previous studies is the use of a ‘control’ arm, which aimed to avoid hyperthermia that can be seen after hypoxic-ischemic brain injury. Additionally, the pediatric arrest population is very different than adults, with a large proportion of primarily respiratory events and smaller proportion of shockable rhythms. Of note is the extremely poor outcomes of these patients overall, with only 12-20% survival with good neurobehavioral status. This suggests the need for continued efforts at prevention and early intervention in the field.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Quality Improvement

Keywords: Adaptation, Psychological, Arrhythmias, Cardiac, Brain Injuries, Child, Coma, Heart Arrest, Hypothermia, Hypothermia, Induced, Incidence, Out-of-Hospital Cardiac Arrest, Outcome Assessment (Health Care), Pediatrics, Survival, Temperature


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