Department of Critical Care Medicine, the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, and the Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, PA, USA.
Pediatr Crit Care Med. 2010 Jan;11(1):66-74. doi: 10.1097/PCC.0b013e3181c58237.
To describe the use and feasibility of therapeutic hypothermia after pediatric cardiac arrest.
Retrospective cohort study.
Pediatric tertiary care university hospital.
Infants and children (age 1 wk to 21 yrs) without complex congenital heart disease with return of spontaneous circulation after in-hospital or out-of-hospital cardiac arrest from 2000 to 2006.
None.
We studied 181 patients after cardiac arrest, of which 91% were asphyxial in etiology (vs. cardiac) and 52% occurred in-hospital. Overall survival to hospital discharge was 45%. Forty patients received therapeutic hypothermia; all were admitted during or after 2002. Sixty percent of patients in the therapeutic hypothermia group had an initial temperature <35 degrees C. The median therapeutic hypothermia target temperature was 34.0 degrees C (33.5-34.8 degrees C), was reached by 7 hrs (5-8 hrs) after admission in patients who were not hypothermic on admission, and was maintained for 24 hrs (16-48 hrs). Re-warming lasted 6 hrs (5-8 hrs). In the therapeutic hypothermia group, temperature <32 degrees C occurred in 15% of patients and was associated with higher hospital mortality (29% vs. 11%; p = .02). Patients treated with therapeutic hypothermia differed from those treated with standard therapy, with more un-witnessed cardiac arrest (p = .04), more doses of epinephrine to achieve return of spontaneous circulation (p = .03), and a trend toward more out-of-hospital cardiac arrests (p = .11). After arrest, therapeutic hypothermia patients received more frequent electrolyte supplementation (p < .05). Standard therapy patients were twice as likely as therapeutic hypothermia patients to have a fever (>38 degrees C) after arrest (37% vs. 18%; p = .02) and trended toward a higher rate of re-arrest (26% vs. 13%; p = .09). Rates of red blood cell transfusions, infection, and arrhythmias were similar between groups. There was no difference in hospital mortality (55.0% therapeutic hypothermia vs. 55.3% standard therapy; p = 1.0), and 78% of the therapeutic hypothermia survivors were discharged home (vs. 68% of the standard therapy survivors; p = .46). In multivariate analysis, mortality was independently associated with initial hypoglycemia or hyperglycemia, number of doses of epinephrine during resuscitation, asphyxial etiology, and longer duration of cardiopulmonary resuscitation, but not treatment group (odds ratio for mortality in the therapeutic hypothermia group, 0.47; p = .2).
This is the largest study reported on the use of therapeutic mild hypothermia in pediatric cardiac arrest to date. We found that therapeutic hypothermia was feasible, with target temperature achieved in <3 hrs overall. Temperature below target range was associated with increased mortality. Prospective study is urgently needed to determine the efficacy of therapeutic hypothermia in pediatric patients after cardiac arrest.
描述儿科心搏骤停后治疗性低温的使用和可行性。
回顾性队列研究。
儿科三级保健大学医院。
2000 年至 2006 年间，患有无复杂先天性心脏病的婴儿和儿童（年龄 1 周至 21 岁），在院内或院外心搏骤停后自主循环恢复。
无。
我们研究了 181 例心搏骤停后的患者，其中 91%为窒息性病因（与心脏性相比），52%发生在院内。总体出院存活率为 45%。40 例患者接受了治疗性低温治疗；所有患者均于 2002 年期间或之后入院。治疗性低温组 60%的患者初始体温<35°C。治疗性低温目标温度中位数为 34.0°C（33.5-34.8°C），在入院时未低温的患者中，入院后 7 小时（5-8 小时）达到目标温度，持续 24 小时（16-48 小时）。复温持续 6 小时（5-8 小时）。在治疗性低温组中，有 15%的患者体温<32°C，与更高的院内死亡率相关（29%比 11%；p =.02）。接受治疗性低温治疗的患者与接受标准治疗的患者存在差异，表现为更多无目击者的心搏骤停（p =.04）、更多剂量的肾上腺素以恢复自主循环（p =.03），并且院外心搏骤停的趋势更为明显（p =.11）。心搏骤停后，治疗性低温组患者更频繁地接受电解质补充治疗（p <.05）。与治疗性低温组相比，标准治疗组患者在复苏后更可能出现发热（>38°C）（37%比 18%；p =.02），且复发性心搏骤停的发生率更高（26%比 13%；p =.09）。两组的红细胞输注、感染和心律失常发生率相似。院内死亡率无差异（治疗性低温组 55.0%比标准治疗组 55.3%；p = 1.0），78%的治疗性低温组幸存者出院回家（标准治疗组幸存者 68%；p =.46）。多变量分析显示，死亡率与初始低血糖或高血糖、复苏期间肾上腺素的剂量、窒息性病因以及心肺复苏持续时间较长独立相关，但与治疗组无关（治疗性低温组死亡率的比值比为 0.47；p =.2）。
这是迄今为止报道的最大规模的儿科心搏骤停后使用治疗性轻度低温的研究。我们发现，治疗性低温是可行的，总体上达到目标温度的时间<3 小时。目标温度以下与死亡率增加相关。急需前瞻性研究来确定治疗性低温在心搏骤停后儿科患者中的疗效。
