Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline

Abstract

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients.DESIGN/PATIENTS: Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases. MAIN RESULTS:The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome. " CONCLUSIONS:In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

About Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest

“…We welcomed the analysis of 57 pediatric patients reported in the literature with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA) that appeared in Pediatric Critical Care Medicine ( 1 ). As a group of special interest clinicians (four are members of the Medical Commission of the International Commission of Alpine Rescue, see https://icar-med.com ), we appreciate this opportunity to raise three points with the authors.…”

“…First, we thank the authors for summarizing the cases published (1963–2023) using the CAse Report (CARE) guideline and checklist ( 2 ), and for making available the details of each case in the Supplementary Digital Content (SDC) ( 1 ). However, although we found it helpful to see the data grouped by type of support—use of extracorporeal membrane oxygenation (ECMO) or not (44 vs. 13) –we would comment on this comparison and the obvious differences between the groups.…”

“…The HOPE score uses six covariates at hospital admission (i.e., age, sex, core temperature, serum potassium, presence of asphyxia, and duration of cardiopulmonary resuscitation) ( 5 ), and there is an online calculator for estimation of survival probability (see https://hypothermiascore.org ). Our second question for the authors is whether they could look at the 44 ECMO cases (using data in their SDC Table S1 [ 1 ]) and calculate the HOPE score. Perhaps the poor outcome of children with drowning-associated hypothermia and OHCA undergoing ECMO is a reflection of very low probability of survival using the HOPE score.…”

“…Perhaps the poor outcome of children with drowning-associated hypothermia and OHCA undergoing ECMO is a reflection of very low probability of survival using the HOPE score. We realize that this test does not follow the 2021 ERC guidelines for pediatrics ( 4 ), but the unique dataset that Andre et al ( 1 ) have collated using the CARE checklist may be a starting point from which the field can better delineate what exactly is meant by “…instead consider expert consultation” ( 3 ). In this context, our views remain: 1) use ECMO to resuscitate hypothermic children with OHCA and no return of spontaneous circulation (ROSC) in the field and 2) use conventional rewarming only in children who have ROSC.…”

“…Finally, we recognize that this area of practice—hypothermia and OHCA—is fraught with a paucity of good data, particularly pediatric. The authors have carried out a valuable 60-year (1963–2023) assessment of the case reports in the literature ( 1 ). We would like to highlight for readers of PCCM our internet-based International Hypothermia Registry (see https://hypothermia-registry.org ).…”