What temperature range is recommended for post-cardiac arrest therapeutic temperature management (TTM) in a comatose patient after Return of Spontaneous Circulation (ROSC)?

Recommended Temperature Range for Post-Cardiac Arrest TTM in Pediatric Patients

Based on the 2019 Pediatric Advanced Life Support guidelines and supporting evidence, the recommended temperature range for post-cardiac arrest therapeutic temperature management in comatose pediatric patients after ROSC is 36.0°C to 37.5°C (Answer D), focusing on targeted normothermia rather than hypothermia. 1

Pediatric-Specific Recommendations

The evidence for pediatric TTM differs substantially from adult recommendations:

• Targeted normothermia (36.0°C-37.5°C) is recommended over hypothermia (32°C-34°C) in comatose children following resuscitation from both out-of-hospital and in-hospital cardiac arrest, regardless of initial rhythm (shockable or non-shockable). 1

• The French expert panel explicitly states: "we do not suggest using TTM between 32 and 34°C to improve survival with good neurological outcome" in pediatric patients (Grade 2 recommendation). 1

Evidence Base from Landmark Pediatric Trials

Two major randomized controlled trials (Moler et al., 2015 and 2017) established the pediatric TTM evidence:

• The THAPCA-OH trial (out-of-hospital cardiac arrest) enrolled 295 pediatric patients and compared TTM at 33°C (32°C-34°C) versus 36.8°C (36°C-37.5°C) for 120 hours. 1

• No difference was found in 28-day mortality (57% TTM vs 67% control, p=0.08) or 12-month survival with favorable neurological outcome. 1

• The THAPCA-IH trial (in-hospital cardiac arrest) enrolled 329 patients with similar temperature targets and duration, showing survival at 28 days and favorable neurological outcome at 1 year of 36% in TTM group versus 39% in control group (no significant difference). 1

• Importantly, the "control" group in both trials maintained normothermia at 36.8°C (range 36°C-37.5°C), not uncontrolled temperature. 1

Critical Distinction from Adult Guidelines

Adult guidelines recommend a broader range of 32°C-36°C, but pediatric evidence does not support hypothermia:

• Adult recommendations allow for temperatures between 32°C and 36°C based on trials showing equivalence between 33°C and 36°C. 1

• In pediatric patients, the two large RCTs specifically tested hypothermia (32°C-34°C) against normothermia (36°C-37.5°C) and found no benefit to the lower temperature range. 1

• Hypothermia in pediatric patients was associated with increased complications including hypokalemia, thrombocytopenia, and more frequent need for renal replacement therapy. 1

Practical Implementation

The target temperature of 36.0°C-37.5°C should be maintained for at least 24 hours, with fever prevention continuing for 72 hours:

• Duration of temperature control in the pediatric trials was 120 hours (5 days), though current practice typically maintains strict temperature control for 24-72 hours. 1

• Active fever prevention (maintaining temperature ≤37.5°C) should continue for at least 72 hours in comatose patients after ROSC. 2, 3

• Continuous core temperature monitoring is essential using esophageal, bladder, or pulmonary artery catheters; axillary and oral measurements are inadequate. 2

Common Pitfalls to Avoid

Do not extrapolate adult hypothermia protocols to pediatric patients:

• The answer options A (26°C-28°C), B (28°C-30°C), and C (30°C-32°C) represent dangerously low temperatures not supported by any guideline evidence and would cause severe complications. 1

• Approximately 38-56% of pediatric cardiac arrest patients present with temperatures requiring active warming to reach normothermia, not cooling. 1

• Prehospital cooling with rapid infusion of large volumes of cold intravenous fluid is not recommended and may cause harm. 1

The correct answer is D: 36.0°C to 37.5°C, representing targeted normothermia with strict fever prevention rather than therapeutic hypothermia. 1