Effect of depth and duration of cooling on deaths in the NICU among neonates with hypoxic ischemic encephalopathy a randomized clinical trial

Seetha Shankaran, Abbot R. Laptook, Athina Pappas, Scott A. McDonald, Abhik Das, Jon E. Tyson, Brenda B. Poindexter, Kurt Schibler, Edward F. Bell, Roy J. Heyne, Claudia Pedroza, Rebecca Bara, Krisa P. Van Meurs, Cathy Grisby, Carolyn M Petrie Huitema, Meena Garg, Richard A. Ehrenkranz, Edward G. Shepherd, Lina F. Chalak, Shannon E G HamrickAmir M. Khan, Anne Marie Reynolds, Matthew M. Laughon, William E. Truog, Kevin C. Dysart, Waldemar A. Carlo, Michele C. Walsh, Kristi L. Watterberg, Rosemary D. Higgins, Michael S. Caplan, Richard A. Polin, Martin Keszler, Betty R. Vohr, Angelita M. Hensman, Elisa Vierira, Emilee Little, Ross Sommers, Birju Shah, Nicholas Guerina, Leslie T. McKinley, Melinda Caskey, Andrea Halbrook, Robert T. Burke, Anna Maria Hibbs, Nancy S. Newman, Eugenia K. Pallotto, Howard W. Kilbride, Cheri Gauldin, Anne Holmes, Kathy Johnson, Suhas G. Kallapur, Barbara Alexander, Estelle E. Fischer, Teresa L. Gratton, Lenora Jackson, Jennifer Jennings, Kristin Kirker, Greg Muthig, Sandra Wuertz, Ronald N. Goldberg, Joanne Finkle, Kimberley A. Fisher, Sandra Grimes, Carl L. Bose, Janice Bernhardt, Cindy Clark, Barbara J. Stoll, David P. Carlton, Ellen C. Hale, Yvonne Loggins, Stephanie Wilson Archer, Gregory M. Sokol, Leslie Dawn Wilson, Dianne E. Herron, Susan Gunn, Lucy Smiley, Sudarshan R. Jadcherla, Pablo J. Sánchez, Patricia Luzader, Christine A. Fortney, Gail E. Besner, Nehal A. Parikh, Dennis Wallace, Kristin M. Zaterka-Baxter, Margaret Crawford, Jenna Gabrio, Marie G. Gantz, Jamie E. Newman, Jeanette O Donnell Auman, Tracy L. Nolen, David K. Stevenson, M. Bethany Ball, Marian M. Adams, Alexis S. Davis, Carol Kibler, Jeffrey R. Parker, Melinda S. Proud, Ronald J. Wong, Namasivayam Ambalavanan, Monica V. Collins, Shirley S. Cosby, Uday Devaskar, Teresa Chanlaw, Rachel Geller, Dan L. Ellsbury, Tarah T. Colaizy, Jane E. Brumbaugh, Karen J. Johnson, Donia B. Campbell, Jacky R. Walker, Jonathan M. Klein, Jeffrey L. Segar, John M. Dagle, Julie B. Lindower, Steven J. McElroy, Glenda K. Rabe, Robert D. Roghair, Lauritz R. Meyer, Cary R. Murphy, Vipinchandra Bhavsar, Robin K. Ohls, Conra Backstrom Lacy, Sandra Beauman, Carol Hartenberger, Barbara Schmidt, Haresh Kirpalani, Sara B. De Mauro, Aasma S. Chaudhary, Soraya Abbasi, Toni Mancini, Dara M. Cucinotta, Nirupama Laroia, Carl T. D'Angio, Ronnie Guillet, Satyan Lakshminrusimha, Karen Wynn, Holly I M Wadkins, Ann Marie Scorsone, Patrick Conway, Michael G. Sacilowski, Stephanie Guilford, Ashley Williams, Myra Wyckoff, Luc P. Brion, Diana M. Vasil, Lijun Chen, Emma Ramon, Kathleen A. Kennedy, Georgia E. McDavid, Julie Arldt-McAlister, Katrina Burson, Carmen Garcia, Karen Martin, Shawna Rodgers, Patti L Pierce Tate, Sharon L. Wright, Beena G. Sood, John Barks, Maria Batts, Lilia De Jesus, Kimberly Hayes-Hart, Mary E. Johnson, Girija Natarajan, Lisa Sulkowski, Laura Sumner, Nicole Walker, Kathleen Weingarden, Mary Christensen, Stephanie A. Wiggins, Christine A. Gleason, Robert J. Boyle, Traci Clemons, Mary E. D'Alton, Carol K. Redmond, Michael G. Ross, Steven J. Weiner, Marian Willinger

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142 Scopus citations

Abstract

IMPORTANCE: Hypothermia at 33.5°C for 72 hours for neonatal hypoxic ischemic encephalopathy reduces death or disability to 44%to 55%; longer cooling and deeper cooling are neuroprotective in animal models.

OBJECTIVE: To determine if longer duration cooling (120 hours), deeper cooling (32.0°C), or both are superior to cooling at 33.5°C for 72 hours in neonates who are full-term with moderate or severe hypoxic ischemic encephalopathy.

DESIGN, SETTING, ANDPARTICIPANTS: Arandomized, 2 × 2 factorial design clinical trial performed in 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network between October 2010 and November 2013.

INTERVENTIONS: Neonates were assigned to 4 hypothermia groups; 33.5°C for 72 hours, 32.0°C for 72 hours, 33.5°C for 120 hours, and 32.0°C for 120 hours.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01192776.

MAIN OUTCOMES AND MEASURES: The primary outcome of death or disability at 18 to 22 months is ongoing. The independent data and safety monitoring committee paused the trial to evaluate safety (cardiac arrhythmia, persistent acidosis, major vessel thrombosis and bleeding, and death in the neonatal intensive care unit [NICU]) after the first 50 neonateswere enrolled, then after every subsequent 25 neonates. The trialwas closed for emerging safety profile and futility analysis after the eighth review with 364 neonates enrolled (of 726 planned). This report focuses on safety and NICU deaths by marginal comparisons of 72 hours' vs 120 hours' duration and 33.5°C depth vs 32.0°C depth (predefined secondary outcomes).

RESULTS The NICU: death rates were 7 of 95 neonates (7%) for the 33.5°C for 72 hours group, 13 of 90 neonates (14%) for the 32.0°C for 72 hours group, 15 of 96 neonates (16%) for the 33.5°C for 120 hours group, and 14 of 83 neonates (17%) for the 32.0°C for 120 hours group. The adjusted risk ratio (RR) for NICU deaths for the 120 hours group vs 72 hours group was 1.37 (95%CI, 0.92-2.04) and for the 32.0°C group vs 33.5°C group was 1.24 (95%CI, 0.69-2.25). Safety outcomes were similar between the 120 hours group vs 72 hours group and the 32.0°C group vs 33.5°C group, except major bleeding occurred among 1%in the 120 hours group vs 3%in the 72 hours group (RR, 0.25 [95%CI, 0.07-0.91]). Futility analysis determined that the probability of detecting a statistically significant benefit for longer cooling, deeper cooling, or both for NICU death was less than 2%.

CONCLUSIONS AND RELEVANCE: Among neonates who were full-term with moderate or severe hypoxic ischemic encephalopathy, longer cooling, deeper cooling, or both compared with hypothermia at 33.5°C for 72 hours did not reduce NICU death. These results have implications for patient care and design of future trials.

Original languageEnglish (US)
Pages (from-to)2629-2639
Number of pages11
JournalJAMA - Journal of the American Medical Association
Volume312
Issue number24
DOIs
StatePublished - Dec 24 2014

ASJC Scopus subject areas

  • Medicine(all)

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    Shankaran, S., Laptook, A. R., Pappas, A., McDonald, S. A., Das, A., Tyson, J. E., Poindexter, B. B., Schibler, K., Bell, E. F., Heyne, R. J., Pedroza, C., Bara, R., Van Meurs, K. P., Grisby, C., Huitema, C. M. P., Garg, M., Ehrenkranz, R. A., Shepherd, E. G., Chalak, L. F., ... Willinger, M. (2014). Effect of depth and duration of cooling on deaths in the NICU among neonates with hypoxic ischemic encephalopathy a randomized clinical trial. JAMA - Journal of the American Medical Association, 312(24), 2629-2639. https://doi.org/10.1001/jama.2014.16058