Therapeutic Hypothermia after Cardiopulmonary Resuscitation in a 4-month Infant

Abstract

Therapeutic hypothermia is currently recommended for adult comatose survivors of cardiac arrest and perinatal hypoxic-ischemic encephalopathy. By contrast, current international guidelines on cardiopulmonary resuscitation in children neither refute nor support therapeutic hypothermia. Here we report on a 4-month old infant who survived resuscitation for severe cardiopulmonary insufficiency without neurological impairments. The infant most probably experienced unwitnessed aspiration with subsequent severe cardiopulmonary insufficiency. This was paralleled by incidental hypothermia, i.e. a core body temperature of 32°C at time of resuscitation. The infant was transported to the pediatric intensive care unit and additional to state-of the art resuscitation therapy (e.g. vasopressors, pressure controlled intermittent mandatory ventilation) therapeutic hypothermia (core body temperature 32.0-34.0°C) was admininistered for additional 48 h to confer optimal neuroprotection. Subsequently, he was rewarmed (0.25°C per hour) and sedation was stopped at a core body temperature of 36°C. Chest X-ray at time of admission to the hospital revealed typical signs of severe aspiration, whereas transthoraic echocardiography, electrocardiography and ultrasound examination of the brain were without pathological findings. Likewise, magnetic resonance imaging of the head performed on days 3 and 32 after resuscitation revealed no signs of hypoxic brain damage and the child was discharged to foster care without neurological deficits 52 days after admission.

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“…Thus far, there has been no uniform scheme for qualifying and conducting MHT in post-SCA children, excluding neonates born with severe PA. In reports from various countries, the core temperature was maintained at 33°C for 12 hours, 24 hours and 48 hours (28,29,33,34) . There is no agerelated relationship forcing the use of any of the schemes.…”

“…There is no agerelated relationship forcing the use of any of the schemes. The general rule seems to be to maintain a core temperature of 32-34°C for a minimum of 24 hours, with the most common procedure being MHT with a core temperature of 33°C for 48 hours (8,30,34) . Upon close examination of the meta-analysis by Moler et al (2015), which includes data on children from 38 hospitals without differentiating the cause or type of SCA, a slightly higher survival rate can be seen in the group of children treated with hypothermia with maintaining a core temperature of 33°C for 48 hours (20% vs. 12%; p = 0.04), with no impact on neurological prognosis (29) .…”

“…None of the above-mentioned studies clearly demonstrated a positive effect of MHT in the group of post-SCA children. This may be due to the aetiology of cardiac arrest in children being different than in the adult population (28,29,34,35) . Children rarely develop SCA from an underlying cardiac cause, in particular shockable rhythms.…”