George Ofori-Amanfo

Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children

BACKGROUND Therapeutic hypothermia is recommended for comatose adults after witnessed out-of-hospital cardiac arrest, but data about this intervention in children are limited. METHODS We conducted this trial of two targeted temperature interventions at 38 childrens hospitals involving children who remained unconscious after out-of-hospital cardiac arrest. Within 6 hours after the return of circulation, comatose patients who were older than 2 days 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 Vineland Adaptive Behavior Scales, second edition (VABS-II), score of 70 or higher (on a scale from 20 to 160, with higher scores indicating better function), was evaluated among patients with a VABS-II score of at least 70 before cardiac arrest. RESULTS A total of 295 patients underwent randomization. Among the 260 patients with data that could be evaluated and who had a VABS-II score of at least 70 before cardiac arrest, there was no significant difference in the primary outcome between the hypothermia group and the normothermia group (20% vs. 12%; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14). Among all the patients with data that could be evaluated, the change in the VABS-II score from baseline to 12 months was not significantly different (P=0.13) and 1-year survival was similar (38% in the hypothermia group vs. 29% in the normothermia group; relative likelihood, 1.29; 95% CI, 0.93 to 1.79; P=0.13). The groups had similar incidences of infection and serious arrhythmias, as well as similar use of blood products and 28-day mortality. CONCLUSIONS In comatose children who survived out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a good functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute and others; THAPCA-OH ClinicalTrials.gov number, NCT00878644.).

Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children

Background Targeted temperature management is recommended for comatose adults and children after out‐of‐hospital cardiac arrest; however, data on temperature management after in‐hospital cardiac arrest are limited. Methods In a trial conducted at 37 childrens hospitals, we 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. 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 to 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 to 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 Among comatose children who survived in‐hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit in survival with a favorable functional outcome at 1 year. (Funded by the National Heart, Lung, and Blood Institute; THAPCA‐IH ClinicalTrials.gov number, NCT00880087.)

Pediatric Postoperative Cardiac Care

Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.

Lung protective ventilation: a summary of the current evidence from the 2012 American Association for Respiratory Care International Congress

Over 150 invited experts presented to almost 6000 participants at the most recent American Association for Respiratory Care International Congress. These participants represented a broad international audience with a range of expertise that included respiratory therapists, physicians, nurses and others. While the program incorporated an extensive curriculum, the theme of lung protective ventilation was highlighted throughout the Congress. Experts reviewed the current evidence regarding the risk for ventilator-induced lung injury in mechanically ventilated patients without pre-existing lung disease and in those with acute lung injury. In addition, several experts reviewed the cutting edge approach of extracorporeal membrane oxygenation as a lung protective approach.

Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest secondary analysis of a randomized clinical trial

Importance Out-of-hospital cardiac arrest (OHCA) occurs in more than 6000 children each year in the United States, with survival rates of less than 10% and severe neurologic morbidity in many survivors. Post–cardiac arrest hypotension can occur, but its frequency and association with survival have not been well described during targeted temperature management. Objective To determine whether hypotension is associated with survival to discharge in children and adolescents after resuscitation from OHCA. Design, Setting, and Participants This post hoc secondary analysis of the Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) trial included 292 pediatric patients older than 48 hours and younger than 18 years treated in 36 pediatric intensive care units from September 1, 2009, through December 31, 2012. Participants underwent therapeutic hypothermia (33.0°C) vs therapeutic normothermia (36.8°C) for 48 hours. All participants had hourly systolic blood pressure measurements documented during the initial 6 hours of temperature intervention. Hourly blood pressures beginning at the time of temperature intervention (time 0) were normalized for age, sex, and height. Early hypotension was defined as a systolic blood pressure less than the fifth percentile during the first 6 hours after temperature intervention. With use of forward stepwise logistic regression, covariates of interest (age, sex, initial cardiac rhythm, any preexisting condition, estimated duration of cardiopulmonary resuscitation [CPR], primary cause of cardiac arrest, temperature intervention group, night or weekend cardiac arrest, witnessed status, and bystander CPR) were evaluated in the final model. Data were analyzed from February 5, 2016, through June 13, 2017. Exposures Hypotension. Main Outcomes and Measure Survival to hospital discharge. Results Of 292 children (194 boys [66.4%] and 98 girls [33.6%]; median age, 23.0 months [interquartile range, 5.0-105.0 months]), 78 (26.7%) had at least 1 episode of early hypotension. No difference was observed between the therapeutic hypothermia and therapeutic normothermia groups in the prevalence of hypotension during induction and maintenance (73 of 153 [47.7%] vs 72 of 139 [51.8%]; P = .50) or rewarming (35 of 118 [29.7%] vs 19 of 95 [20.0%]; P = .10) during the first 72 hours. Participants who had early hypotension were less likely to survive to hospital discharge (20 of 78 [25.6%] vs 93 of 214 [43.5%]; adjusted odds ratio, 0.39; 95% CI, 0.20-0.74). Conclusions and Relevance In this post hoc secondary analysis of the THAPCA trial, 26.7% of participants had hypotension within 6 hours after temperature intervention. Early post–cardiac arrest hypotension was associated with lower odds of discharge survival, even after adjusting for covariates of interest.

Natural history of nonimmune‐mediated thrombocytopenia and acute kidney injury in pediatric open‐heart surgery

Thrombocytopenia and acute kidney injury (AKI) are common following pediatric cardiac surgery with cardiopulmonary bypass (CPB). However, the relationship between postoperative nadir platelet counts and AKI has not been investigated in the pediatric population. Our objective was to investigate this relationship and examine independent predictors of AKI.

Paediatric in-hospital cardiac arrest: Factors associated with survival and neurobehavioural outcome one year later

OBJECTIVE To investigate clinical characteristics associated with 12-month survival and neurobehavioural function among children recruited to the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital trial. METHODS Children (n = 329) with in-hospital cardiac arrest who received chest compressions for ≥2 min, were comatose, and required mechanical ventilation after return of circulation were included. Neurobehavioural function was assessed using the Vineland Adaptive Behaviour Scales, second edition (VABS-II) at baseline (reflecting pre-arrest status) and 12 months post-arrest. Norms for VABS-II are 100 (mean) ±15 (SD). Higher scores indicate better functioning. Outcomes included 12-month survival, 12-month survival with VABS-II decreased by ≤15 points from baseline, and 12-month survival with VABS-II ≥70. RESULTS Asystole as the initial arrest rhythm, administration of >4 adrenaline doses, and higher post-arrest blood lactate concentration were independently associated with lower 12-month survival; an adrenaline dosing interval of 3-<5 min and open chest compressions were independently associated with greater 12-month survival. Use of extracorporeal membrane oxygenation (ECMO) and higher blood lactate were independently associated with lower 12-month survival with VABS-II decreased by ≤15 points from baseline; open chest compressions was independently associated with greater 12-month survival with VABS-II decreased by ≤15 points. Asystole as the initial rhythm, use of ECMO, and higher blood lactate were independently associated with lower 12-month survival with VABS-II ≥70; open chest compressions was independently associated with greater 12-month survival with VABS-II ≥70. CONCLUSIONS Cardiac arrest and resuscitation factors are associated with long-term survival and neurobehavioural function among children who are comatose after in-hospital arrest.

Correlation between minute carbon dioxide elimination and pulmonary blood flow in single-ventricle patients after stage 1 palliation and 2-ventricle patients with intracardiac shunts: A pilot study

Assessment of pulmonary blood flow and cardiac output is critical in the postoperative management of patients with single‐ventricle physiology or 2‐ventricle physiology with intracardiac shunting. Currently, such hemodynamic data are only obtainable by invasive procedures, such as cardiac catheterization or the use of a pulmonary artery catheter. Ready availability of such information, especially if attainable noninvasively, could be a valuable addition to postoperative management.

Cardiopulmonary resuscitation in hospitalized infants

BACKGROUND Hospitalized infants requiring cardiopulmonary resuscitation (CPR) represent a high-risk group. Recent data on risk factors for mortality following CPR in this population are lacking. AIMS We hypothesized that infant demographic characteristics, diagnoses, and levels of cardiopulmonary support at the time of CPR requirement would be associated with survival to hospital discharge following CPR. STUDY DESIGN Retrospective cohort study. SUBJECTS All infants receiving CPR on day of life 2 to 120 admitted to 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. OUTCOMES MEASURES We collected data on demographics, interventions, center volume, and death prior to NICU discharge. We evaluated predictors of death after CPR using multivariable logistic regression with generalized estimating equations to account for clustering of the data by center. RESULTS Our cohort consisted of 2231 infants receiving CPR. Of these, 1127 (51%) survived to hospital discharge. Lower gestational age, postnatal age, 5-min APGAR, congenital anomaly, and markers of severity of illness were associated with higher mortality. Mortality after CPR did not change significantly over time (Cochran-Armitage test for trend p=0.35). CONCLUSIONS Mortality following CPR in infants is high, particularly for less mature, younger infants with congenital anomalies and those requiring cardiopulmonary support prior to CPR. Continued focus on at risk infants may identify targets for CPR prevention and improve outcomes.

339: ABDOMINAL NIRS CORRELATES WITH PULSE DOPPLER MEASUREMENTS OF CELIAC ARTERY RESISTIVE INDICIES

older, undergoing cardiac surgery with or without cardiopulmonary bypass, who received at least one dose of perioperative TXA between October 2011 and October 2012 or EACA between January 2010 and October 2011. Patients undergoing cardiac transplant, left ventricular assist device, or congenital defect surgery were excluded from this study. The primary efficacy outcome of this study, massive perioperative blood loss, was a composite end points of chest tube drainage greater than 1,500 mL of blood in any eight hour period after surgery, perioperative transfusion of ten or more units of packed red blood cells, reoperation for bleeding, or death from hemorrhage within 30 days. The secondary safety outcome measures were the number of patients with thromboembolic event, postoperative renal impairment, seizure, and 30-day all-cause mortality. Results: The study included 120 patients with 60 patients in the TXA group and 60 patients in the EACA group. There were no statistically significant differences among any of the baseline characteristics, except for the American Society of Anesthesiologists (ASA) Score with higher scores in the EACA group (p=0.05) and intraoperative protamine dose with higher doses in the EACA group (p=0.003). In addition, more patients in the TXA group had renal insufficiency and more patients in the EACA had diabetes at baseline. The primary endpoint, massive perioperative bleeding occurred in 10 patients (16.7%) in the TXA group compared to 5 patients (8.3%) in the EACA group (p=0.17). There were no statistically significant differences in the secondary endpoints of 30 day mortality, thromboembolic events, renal impairment, and seizures. Conclusions: Based on the results of this study, the authors concluded that there were no statistically significant differences between TXA and EACA in the primary and secondary outcomes. Furthermore, the outcome trends observed in this study are similar to those observed in the BART trial. Considering the substantial cost difference and comparable efficacy and safety, EACA may have better clinical value for reducing surgical bleeding in cardiovascular surgery.