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Should children who have a cardiac arrest be treated with therapeutic hypothermia?

BMJ 2014; 348 doi: (Published 16 January 2014) Cite this as: BMJ 2014;348:f7672
  1. Barnaby R Scholefield, consultant in paediatric intensive care and senior clinical research fellow12,
  2. Gavin D Perkins, professor in critical care medicine3,
  3. Heather P Duncan, consultant in paediatric intensive care1,
  4. Fang Gao, professor of anaesthesia, critical care and pain2,
  5. Kevin P Morris, consultant in paediatric intensive care, and honorary senior lecturer1
  1. 1Intensive Care Unit, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
  2. 2Perioperative, Anaesthesia and Critical Care Trials Group, University of Birmingham, Birmingham B15 2TT, UK
  3. 3University of Warwick and Heart of England NHS Foundation Trust, Coventry, UK
  1. Correspondence to: B R Scholefield Barney.scholefield{at}
  • Accepted 31 October 2013

The International Liaison Committee for Resuscitation recommends that comatose adult patients with spontaneous circulation after cardiac arrest are cooled to 32-34°C for 12-24 hours based on analysis of data from two randomised controlled trials and 17 observational studies.1 However, these studies were mostly in a specific subgroup of cardiac arrest patients with witnessed, out-of-hospital ventricular fibrillation, and evidence of benefit in the general population of cardiac arrest patients has been less certain.2 The rationale for therapeutic hypothermia is that it can reduce cerebral metabolism, attenuate biosynthesis of excitotoxic compounds, reduce free radical production, reduce inflammation, and regulate gene and protein expressions associated with necrotic and apoptotic pathways during ischaemia and reperfusion.3

Recommendations for treatment in children4 (box 1) are based almost solely on adult data. However, the aetiology of cardiac arrest is very different in children,5 possibly altering the pattern of neuronal injury. Most cardiac arrests are secondary to a respiratory cause with profound hypoxia, and primary cardiac causes of arrests, including ventricular fibrillation, are rare. In other clinical situations, therapeutic hypothermia has been seen to be both beneficial (newborns with hypoxic brain injury within 6 hours of birth)6 and potentially harmful (traumatic brain injury).7 It is therefore important that the question of whether children with cardiac arrest should be treated with therapeutic hypothermia is addressed.

Box 1: Recommendations for use of therapeutic hypothermia after paediatric cardiac arrest (International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations4)

  • Therapeutic hypothermia (32-34°C) may be beneficial for adolescents who remain comatose after resuscitation from sudden, witnessed, out-of-hospital, ventricular fibrillation cardiac arrest

  • Therapeutic hypothermia (32-34°C) may be considered for infants and children who remain comatose after resuscitation from cardiac arrest

What is the evidence of uncertainty?

Our recent Cochrane systematic …

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