Tanaka T, Nagase H, Yamaguchi H, Ishida Y, Tomioka K, Nishiyama M, Toyoshima D, Maruyama A, Fujita K, Nozu K, Nishimura N, Kurosawa H, Tanaka R, Iijima K. Predicting the outcomes of targeted temperature management for children with seizures and/or impaired consciousness accompanied by fever without known etiology. Brain Dev. 2019 Mar 28. pii: S0387-7604(18)30568-0. doi:10.1016/j.braindev.2019.03.007. [Epub ahead of print]
Seizures and/or impaired consciousness accompanied by fever without known etiology (SICF) is common in the pediatric emergency setting. No optimal strategy for the management of SICF in childhood currently exists. We previously demonstrated the effectiveness of targeted temperature management (TTM) against SICF with a high risk of morbidity; however, some patients with SICF develop neurological sequelae despite TTM, which necessitate additional neuroprotective treatment. The clinical characteristics of these severe cases have not been studied. Accordingly, the aim of this study was to identify the clinical characteristics of children with SICF who exhibit poor outcomes after TTM.
The medical records of children admitted to Kobe Children's Hospital (Kobe, Japan) between October 2002 and September 2016 were retrospectively reviewed. Patients with SICF treated using TTM were included and divided into the satisfactory and poor outcome groups. Univariate and multivariate logistic regression analyses were used to compare clinical characteristics and laboratory findings between the two groups.
Of the 73 included children, 10 exhibited poor outcomes. Univariate logistic regression analysis revealed that acute circulatory failure before TTM initiation, the use of four or more types of anticonvulsants, methylprednisolone pulse therapy, and an aspartate aminotransferase (AST) level ≥73 IU/L were associated with poor outcomes. Multivariate logistic regression analysis identified an elevated AST level as a significant independent predictor of a poor outcome.
An elevated AST level within 12 h of onset in children with SICF is an independent predictor of a poor outcome after TTM initiated within 24 h of onset.
A total of 10 children in the final cohort were categorized into the poor outcomes group and 63 patients exhibited satisfactory outcomes. In the univariate analysis, factors associated with poor outcomes included treatment with ≥4 types of anticonvulsants, use of methylprednisolone pulse therapy, and an AST level ≥73 IU/L.
The multivariate analysis, however, demonstrated that an elevated AST level was the only independent predictor of poor outcome in these patients (odds ratio, 26.50; 95% CI, 4.75-148.00; P <.001). Of the 10 patients who had a poor outcome, 8 were subsequently diagnosed with acute encephalopathy with biphasic seizures and late reduced diffusion.
Study limitations include its retrospective nature, the small sample size, and the lack of a comparator control group.
The investigators concluded that “future large-scale studies are required to confirm whether high AST levels are an independent predictor of a poor outcome in children with SICF treated using TTM.”