title: Early microcirculatory impairment during therapeutic hypothermia is associated with poor outcome in post-cardiac arrest children: a prospective observational cohort study.
abstract: OBJECTIVE
  This study aimed to evaluate if the microcirculation is impaired during and after therapeutic hypothermia (TH) in children with return of spontaneous circulation after cardiac arrest (CA) and to assess if microcirculatory impairment predicts mortality. This has been reported for post-CA adults, but results might be different for children because etiology, pathophysiology, and mortality rate differ.
  
  
  METHODS
  This prospective observational cohort study included consecutive, non-neonatal post-CA children receiving TH upon intensive care admission between June 2008 and June 2012. Also included were gender-matched and age-matched normothermic, control children without cardiorespiratory disease. The buccal microcirculation was non-invasively assessed with Sidestream Dark Field Imaging at the start of TH, halfway during TH, at the start of re-warming, and at normothermia. Macrocirculatory, respiratory, and biochemical parameters were also collected.
  
  
  RESULTS
  Twenty post-CA children were included of whom 9 died. During hypothermia, the microcirculation was impaired in the post-CA patients and did not change over time. At normothermia, the core body temperature and the microcirculation had increased and no longer differed from the controls. Microcirculatory deterioration was associated with mortality in the post-CA patients. In particular, the microcirculation was more severely impaired at TH start in the non-survivors than in the survivors - positive predictive value: 73-83, negative predictive value: 75-100, sensitivity: 63-100%, and specificity: 70-90%.
  
  
  CONCLUSIONS
  The microcirculation is impaired in post-CA children during TH and more severe impairment at TH start was associated with mortality. After the stop of TH, the microcirculation improves rapidly irrespective of outcome.
authors.affiliation: Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands. Electronic address: e.a.b.buijs@erasmusmc.nl.
authors.forename: Erik A B
authors.initials: EA
authors.lastname: Buijs
authors.affiliation: Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands. Electronic address: e.verboom@erasmusmc.nl.
authors.forename: Elyse M
authors.initials: EM
authors.lastname: Verboom
authors.affiliation: Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, United Kingdom. Electronic address: anke.top@bch.nhs.uk.
authors.forename: Anke P C
authors.initials: AP
authors.lastname: Top
authors.affiliation: Department of Biostatistics, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. Electronic address: e.andrinopoulou@erasmusmc.nl.
authors.forename: Eleni-Rosalina
authors.initials: ER
authors.lastname: Andrinopoulou
authors.affiliation: Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands. Electronic address: c.buysse@erasmusmc.nl.
authors.forename: Corinne M P
authors.initials: CM
authors.lastname: Buysse
authors.affiliation: Intensive Care, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. Electronic address: c.ince@erasmusmc.nl.
authors.forename: Can
authors.initials: C
authors.lastname: Ince
authors.affiliation: Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands. Electronic address: d.tibboel@erasmusmc.nl.
authors.forename: Dick
authors.initials: D
authors.lastname: Tibboel
mesh_terms: D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006323:Heart Arrest / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects*; D007223:Infant; D008297:Male; D008833:Microcirculation; D011379:Prognosis; D011446:Prospective Studies
keywords: Cardiac arrest; Children; Microcirculation; Mortality; Therapeutic hypothermia