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Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h418 (Published 10 February 2015) Cite this as: BMJ 2015;350:h418
  1. J K Kieboom, paediatric intensivist1,
  2. H J Verkade, paediatric gastroenterologist1,
  3. J G Burgerhof, statistician2,
  4. J J Bierens, anaesthesiologist3,
  5. P F van Rheenen, paediatric gastroenterologist1,
  6. M C Kneyber, paediatric intensivist1,
  7. M J Albers, paediatric intensivist4
  1. 1Department of Paediatrics, Beatrix Children’s Hospital, University Medical Centre Groningen, University of Groningen, Netherlands
  2. 2Department of Epidemiology University Medical Centre Groningen, University of Groningen, Netherlands
  3. 3Van Heurnlaan 10-Anaesthesiology, Vught, Netherlands
  4. 4Department of Paediatrics, St Elizabeth’s Hospital, Tilburg, Netherlands
  1. Correspondence to: J Kieboom j.k.w.kieboom{at}umcg.nl
  • Accepted 13 December 2014

Abstract

Objectives To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation.

Design Nationwide retrospective cohort study.

Setting Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands.

Participants Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.

Main outcome measure Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥4).

Results From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.

Conclusions Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

Footnotes

  • We thank the physicians of the paediatric intensive care units participating in the Stichting Kinder Intensive Care. The participating units were the university medical centres of Amsterdam (AMC, J B M van Woensel and A P Bos, and VUMC, D G Markhorst and F B Plötz), Leiden (LUMC, N A M van Dam and B J Gesink), Nijmegen (Radboud MC, C Neeleman and L G F M van ‘t Hek), Maastricht (MMC, D A van Waardenburg and G D Vos), Rotterdam (Erasmus MC, M de Hoog and D Tibboel), and Utrecht (UMCU, N J G Jansen and A J van Vught). We thank N M Turner, medical director of the Dutch Foundation for the Emergency Medical Care of Children, for his help with the English language.

  • Contributors: JKK, JJB, and MJA contributed to the study design. JKK and S A van der Linden and J R Prins (medical students at University of Groningen) collected the data. All authors contributed to the analysis, drafting of the manuscript, and approved the final version. All authors had full access to all of the data and can take responsibility for the integrity of the data and the accuracy of the data analysis. JKK is guarantor.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: The relevant anonymised patient level data are available on reasonable request from JK.

  • Transparency declaration: JKK affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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