In children who suffer out of hospital cardiac arrest, targeted hypothermia at 33.0 C confers no benefit when compared to targeted normothermia at 36.8 C. Level of evidence: 2B (RCT with wide CIs)Appraised by: Andrew Claxton Citation: Moler FW, Silverstein FS, Holubkov R and the THAPCA Trial Investigators. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Eng

BACKGROUND-Targeted temperature management is recommended for comatose adults and children after out-of-hospital cardiac arrest; however, data on temperature management after inhospital cardiac arrest are limited.

Objectives In-hospital cardiac arrest (CA) occurs in 2.6%–6% of children with cardiac disease and is associated with significant morbidity and mortality. Much remains unknown about CA in pediatric cardiac intensive care units (CICU), therefore we aimed to describe CA epidemiology in a contemporary multicenter CICU cohort. Design Retrospective analysis within the Pediatric Cardiac Critical Care Consortium (PC4) clinical registry. Setting CICUs within 23 North American hospitals Patients All cardiac medical and surgical patients admitted from 8/2014–7/2016 Interventions None Measurements and Main Results There were 15,908 CICU encounters (6498 medical, 9410 surgical). 3.1% had CA; rate was 4.8 CA/1000 CICU days. Medical encounters had 50% higher rate of CA compared to surgical encounters. Observed (unadjusted) CICU CA prevalence varied from 1–5.5% among the 23 centers; CA/1000 CICU days varied from 1.1 to 10.4. Over half CA occur within 48hrs of admission. On multivariable analysis, prematurity, neonatal age, any Society of Thoracic Surgeons preoperative risk factor, and STS-European Association for Cardiothoracic Surgery mortality category 4,5 had strongest association with surgical encounter CA. In medical encounters independent CA risk factors were acute heart failure, prematurity, lactic acidosis >3mmol/dL, and invasive ventilation 1hr after admission. Median cardiopulmonary resuscitation (CPR) duration was ten minutes, return of spontaneous circulation occurred in 64.5%, extracorporeal CPR in 27.2%. Unadjusted survival was 53.2% in encounters with CA vs. 98.2% without. Medical encounters had lower survival after CA (37.7%) vs. surgical encounters (62.5%); Norwood patients had less than half the survival after CA (35.6%) compared to all others. Unadjusted survival after CA varied greatly among 23 centers. Conclusions We provide contemporary epidemiologic and outcome data for CA occurring in the CICU from a multicenter clinical registry. As detailed above, we highlight high-risk patient cohorts and periods of time that may serve as targets for research and QI initiatives aimed at CA prevention.

Objective To describe the clinical epidemiology of extubation failure in a multicenter cohort of patients treated in pediatric cardiac ICUs. Design Retrospective cohort study using prospectively collected clinical registry data. Setting Pediatric Cardiac Critical Care Consortium registry. Patients All patients admitted to the CICU at Pediatric Cardiac Critical Care Consortium hospitals. Interventions None. Measurements and Main Results Analysis of all mechanical ventilation episodes in the registry from October 1, 2013, to July 31, 2014. The primary outcome of extubation failure was reintubation less than 48 hours after planned extubation. Repeated-measures analysis using generalized estimating equations to account for within patient and center correlation was performed to identify risk factors for extubation failure. Adjusted extubation failure rates for each hospital were calculated using logistic regression controlling for patient factors. Of 1,734 mechanical ventilation episodes (1,478 patients at eight hospitals) ending in a planned extubation, there were 100 extubation failures (5.8%). In multivariable analysis, only longer duration of mechanical ventilation was significantly associated with extubation failure (p = 0.01); the failure rate was 4% when ventilated less than 24 hours, 9% after 24 hours, and 13% after 7 days. For 503 patients intubated and extubated in the cardiac operating room, 15 patients (3%) failed extubation within 48 hours (12 within 24 hr). Case-mix-adjusted extubation failure rates ranged from 1.1% to 9.8% across hospitals. Patients failing extubation had greater median cardiac ICU length of stay (15 vs 3 d; p < 0.001) and in-hospital mortality (7.9 vs 1.2%; p < 0.001). Conclusions Though extubation failure is uncommon overall, there may be opportunities to improve extubation readiness assessment in patients ventilated more than 24 hours. These data suggest that extubation in the operating room after cardiac surgery can be done with a low failure rate. We observed variation in extubation failure rates across hospitals, and future investigation must elucidate the optimal strategies of high-performing centers to reduce ventilation time while limiting extubation failures.

The optimum heparin monitoring method during extracorporeal membrane oxygenation (ECMO) is unknown. We report a protocol utilizing only anti-factor Xa (anti-Xa) to manage anticoagulation in 22 consecutive ECMO patients. Anti-Xa was monitored with heparin titration every hour until goal 0.4-0.8 IU/ml. Once therapeutic, monitoring was progressively spaced up to every 6 hours. Patients received frequent antithrombin III (ATIII). Extracorporeal membrane oxygenation indications were as follows: 13 cardiorespiratory failures, eight extracorporeal cardiopulmonary resuscitations (ECPRs), and one pulmonary hypertension. Median weight was 4 kg, age 12.5 days, and ECMO duration 88 hours. Survival was 50%. Mean heparin dose was 38 ± 11 unit/kg/hr. Eight patients received no heparin for median 9 hours because of postoperative bleeding. Compared with prior activated clotting time (ACT) protocol, there were 20 fewer blood draws per day to manage anticoagulation, p < 0.001. Only 9% of the anti-Xa levels were outside therapeutic range versus 22% using ACT, p < 0.01. Six patients had bleeding complications, and seven had oxygenator change-out. Change-out was associated with blood product administration and bleeding but not with heparin-free period (p = 0.39). Survival to discharge was higher among those who did not require circuit/oxygenator change-outs, 4/7 versus 7/7 (p < 0.01). Anti-factor Xa-based ECMO heparin management protocol is feasible, decreases blood sampling and heparin infusion adjustments, and does not appear to increase complications.