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Therapeutic Hypothermia After Pediatric Cardiac Arrest
Study Questions:
What is the efficacy of therapeutic hypothermia (target temperature, 33.0°C) with that of therapeutic normothermia (target temperature, 36.8°C) in comatose children and adolescents who were resuscitated after in-hospital cardiac arrest?
Methods:
This trial, conducted at 37 children’s hospitals, compared two temperature interventions in children who had had in-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose children older than 48 hours and younger than 18 years of age were randomly assigned to therapeutic hypothermia (target temperature, 33.0°C) or therapeutic normothermia (target temperature, 36.8°C). The primary efficacy outcome, survival at 12 months after cardiac arrest with a score of 70 or higher on the Vineland Adaptive Behavior Scales, second edition (VABS-II, on which scores range from 20 to 160, with higher scores indicating better function), was evaluated among patients who had had a VABS-II score of at least 70 before the cardiac arrest. The primary outcome and 12-month survival were compared between the treatment groups with the use of a Cochran–Mantel–Haenszel test stratified according to age category.
Results:
The trial was terminated because of futility after 329 patients had undergone randomization. Among the 257 patients who had a VABS-II score of at least 70 before cardiac arrest and who could be evaluated, the rate of the primary efficacy outcome did not differ significantly between the hypothermia group and the normothermia group (36% [48 of 133 patients] and 39% [48 of 124 patients], respectively; relative risk, 0.92; 95% confidence interval [CI], 0.67-1.27; p = 0.63). Among 317 patients who could be evaluated for change in neurobehavioral function, the change in VABS-II score from baseline to 12 months did not differ significantly between the groups (p = 0.70). Among 327 patients who could be evaluated for 1-year survival, the rate of 1-year survival did not differ significantly between the hypothermia group and the normothermia group (49% [81 of 166 patients] and 46% [74 of 161 patients], respectively; relative risk, 1.07; 95% CI, 0.85-1.34; p = 0.56). The incidences of blood-product use, infection, and serious adverse events, as well as 28-day mortality, did not differ significantly between groups.
Conclusions:
The authors concluded that therapeutic hypothermia did not confer a significant benefit in survival, with a favorable functional outcome at 1 year among comatose children who survived in-hospital cardiac arrest.
Perspective:
This study reports that in comatose children who survived in-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit with respect to survival with a good functional outcome at 1 year. Additional trials combining targeted temperature management with neuroprotective agents might be considered in the future to improve outcomes after cardiac arrest in children.
Keywords: Adolescent, Arrhythmias, Cardiac, Coma, Heart Arrest, Hypothermia, Hypothermia, Induced, Neurobehavioral Manifestations, Neuroprotective Agents, Pediatrics, Secondary Prevention, Survival
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