The recent publication of THAPCA-OH filled an important gap in our knowledge. THAPCA does not support cooling children after cardiac arrest which was a common practice until recently in many units.It is illustrative to look at how a practice became routine with no supporting evidence at it raises questions about what questions we ask and how we operate in the absence of good evidence.

1. We should provide therapeutic
hypothermia for children after
cardiac arrest

2. Overview
• Evidence for TH
• Recent evidence that does not support TH
• Unanswered questions about TH

3. Definitions
Targeted temperature management (TTM)
Controlling core body temperature around a set
number.
Therapeutic hypothermia (TH)
Controlling core body temperature at a
temperature below 35 degrees.

4. Evidence for therapeutic hypothermia

5. Evidence for therapeutic hypothermia

6. Evidence for therapeutic hypothermia

7. The effect of the evidence on world
wide practice.
• Neonatal standard of care = cooling 32-34
• 2003 Adult ILCOR guideline = cooling 32-34
• 2006 ILCOR added 32-34 may be:
(1) beneficial for adolescents
(2) considered for infants and children
• 2011 survey of paediatric services in UK – 50%
cooled.

8. Evidence for targeted temperature

9. Evidence for targeted temperature

10. Evidence for targeted temperature

11. Therapeutic Hypothermia After Paediatric
Cardiac Arrest – out of hospital
Primary outcome
• Neurological survival at 12 months – no
difference
Secondary outcome
Mean survival time Hypothermia 149±14 days
Normothermia 119±14 days
(p=0.04)

12. Therapeutic Hypothermia After Paediatric
Cardiac Arrest – out of hospital
• A pre-determined effect size of 20% was set.
• The study was not powered to measure a
difference between the 2 groups of less than
20%.
The authors state:
‘A clinically significant benefit cannot be ruled
out………A larger trial might have detected or
rejected a smaller intervention effect’

13. Children’s OH cardiac arrests are very
different to adults
• 72% respiratory cause for arrest
• 8% shockable rhythms
• Adult studies – 100% cardiac cause for arrest

14. Unanswered questions in targeted
temperature management
Described by the THAPCA authors
• What is the optimum target temperature
• Does it matter how quickly cooling is started?
(prehospital, during CPR, post-ROSC?)
• What is the optimum duration of targeted
temperature management?

15. Unanswered questions in targeted
temperature management
Others
• Should VT/VF be treated differently to non-
VT/VF?
• In-hospital cardiac arrest management –
THAPCA–IN
• Should some patients have different target
temperatures?

16. Summary
YES
Targeted temperature management should be
provided to children in randomised control
trials.
Trials should be multi-national, multicentre.

17. References
Neonatal
Edwards, A D.; Brocklehurst, P.; Gunn, A. J; Halliday, H.; Juszczak, E.; Levene, M.; Strohm, B.; Thoresen, M.; Whitelaw, A.; Azzopardi, D. (2010). "Neurological
outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: Synthesis and meta-analysis of trial data". BMJ
340: c363. doi:10.1136/bmj.c363. PMC 2819259. PMID 20144981.
Field D, Juszczak E, Linsell L, et al. Neonatal ECMO Study of Temperature (NEST): a randomized controlled trial. Pediatrics 2013;132(5):e1247-e1256.
Paediatric
Doherty DR, Parshuram CS, Gaboury I, et al. Hypothermia therapy after pediatric cardiac arrest. Circulation 2009;119: 1492-500.
Fink EL, Clark RS, Kochanek PM, Bell MJ, Watson RS. A tertiary care center’s experience with therapeutic hypothermia after pediatric cardiac arrest. Pediatr
Crit Care Med 2010;11:66-74.
Adult
The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N
Engl J Med 2002; 346:549-56.
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J
Med 2002;346:557-63.
Cooling speed
Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest
Castrén M1, Nordberg P, Svensson L, Taccone F, Vincent JL, Desruelles D, Eichwede F, Mols P, Schwab T, Vergnion M, Storm C, Pesenti A, Pachl J, Guérisse F,
Elste T, Roessler M, Fritz H, Durnez P, Busch HJ, Inderbitzen B, Barbut D. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter
study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Circulation. 2010 Aug 17;122(7):729-36. doi: 10.1161/CIRCULATIONAHA.109.931691. Epub 2010
Aug 2.
Nordberg P, Taccone FS, Castren M, et al. Design of the PRINCESS trial: Pre-hospital Resuscitation Intra-Nasal Cooling Effectiveness Survival Study
(PRINCESS). BMC Emerg Med 2013; 13:21.

18. ‘Out of hospital’ is very different to ‘in
hospital’ arrests
• Pre-arrest neurological status was normal in 66%
OH cases (83% IH).
• Pre-existing conditions were 49% in OH cases
(88% IH).
• OH – respiratory cause (72%), IH – cardiac cause
(58%)
• Neuro status was changed at discharge 56% IH
and 76% OH.
• Cause of death neurological 69% for OH, 20% for
IH.

19. Greg Kelly

20. • Phil Hyde is a nice
guy

21. • Phil is a smart guy

22. • Phil and had a drink
on Tuesday and
each conceded that
the other had some
points