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Acar YA, Karakuş Yılmaz B, Çelik DS, Çevik E, Topçu H, Özsoy Ş, Haklıgör A, Çınar O. Transpulmonary Hypothermia with Cooled Oxygen Inhalation Shows Promising Results as a Novel Hypothermia Technique. Balkan Med J 2017; 34:212-218. [PMID: 28443564 PMCID: PMC5450860 DOI: 10.4274/balkanmedj.2016.0782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Therapeutic hypothermia was showed to improve neurologic outcome but current therapeutic hypothermia techniques have limitations. Novel techniques such as transpulmonary hypothermia with cooled oxygen inhalation may be beneficial. Aims: To evaluate the performance of transthoracic hypothermia with cooled medical oxygen inhalation as a therapeutic hypothermia method. Study Design: Animal experimentation. Methods: A total of 36 adult male Wistar-Hannover rats were used in this research. Rats were randomised into four groups: group 1, Cooled oxygen group; group 2, IV cold fluid group; group 3, Surface cooling group; group 4, control group. No hypothermia method was applied in the control group. Hypothermia techniques were administered in the other three groups until the targeted core temperature was maintained. The target temperature was continued for one hour at 32-34 °C. After that, rats were heated up with hot blankets. Once the rectal temperature reached 38 °C, rats were euthanised. The main outcomes were the rate of temperature decrease (°C per minute) (S) and the time required to reach the target body temperature (T). Results: All rats survived the study protocol. When compared to the control group, T and S values were better in the cooled medical oxygen inhalation group (p<0.001). The IV cold fluid group had lower S values and higher T values compared to the cooled oxygen group (p<0.001, and p=0.003, respectively). There was no meaningful pathology in the histological samples in any group. Conclusion: As an easy-to-use and inexpensive method, cooled oxygen inhalation may be a beneficial hypothermia technique.
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Affiliation(s)
- Yahya Ayhan Acar
- Clinic of Emergency Medicine, Etimesgut Military Hospital, Ankara, Turkey
| | - Banu Karakuş Yılmaz
- Clinic of Emergency Medicine, Hamidiye Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Duygu Sultan Çelik
- Research Center, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Erdem Çevik
- Clinic of Emergency Medicine, Van Military Hospital, Van, Turkey
| | - Hatice Topçu
- Clinic of Emergency Medicine, Hamidiye Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Şule Özsoy
- Clinic of Pathology, Bağcılar Training and Research Hospital, İstanbul, Turkey
| | - Aylin Haklıgör
- Clinic of Biochemistry, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Orhan Çınar
- Department of Emergency Medicine, Acıbadem University School of Medicine, İstanbul, Turkey
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Wallach JD, Sullivan PG, Trepanowski JF, Sainani KL, Steyerberg EW, Ioannidis JPA. Evaluation of Evidence of Statistical Support and Corroboration of Subgroup Claims in Randomized Clinical Trials. JAMA Intern Med 2017; 177:554-560. [PMID: 28192563 PMCID: PMC6657347 DOI: 10.1001/jamainternmed.2016.9125] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many published randomized clinical trials (RCTs) make claims for subgroup differences. OBJECTIVE To evaluate how often subgroup claims reported in the abstracts of RCTs are actually supported by statistical evidence (P < .05 from an interaction test) and corroborated by subsequent RCTs and meta-analyses. DATA SOURCES This meta-epidemiological survey examines data sets of trials with at least 1 subgroup claim, including Subgroup Analysis of Trials Is Rarely Easy (SATIRE) articles and Discontinuation of Randomized Trials (DISCO) articles. We used Scopus (updated July 2016) to search for English-language articles citing each of the eligible index articles with at least 1 subgroup finding in the abstract. STUDY SELECTION Articles with a subgroup claim in the abstract with or without evidence of statistical heterogeneity (P < .05 from an interaction test) in the text and articles attempting to corroborate the subgroup findings. DATA EXTRACTION AND SYNTHESIS Study characteristics of trials with at least 1 subgroup claim in the abstract were recorded. Two reviewers extracted the data necessary to calculate subgroup-level effect sizes, standard errors, and the P values for interaction. For individual RCTs and meta-analyses that attempted to corroborate the subgroup findings from the index articles, trial characteristics were extracted. Cochran Q test was used to reevaluate heterogeneity with the data from all available trials. MAIN OUTCOMES AND MEASURES The number of subgroup claims in the abstracts of RCTs, the number of subgroup claims in the abstracts of RCTs with statistical support (subgroup findings), and the number of subgroup findings corroborated by subsequent RCTs and meta-analyses. RESULTS Sixty-four eligible RCTs made a total of 117 subgroup claims in their abstracts. Of these 117 claims, only 46 (39.3%) in 33 articles had evidence of statistically significant heterogeneity from a test for interaction. In addition, out of these 46 subgroup findings, only 16 (34.8%) ensured balance between randomization groups within the subgroups (eg, through stratified randomization), 13 (28.3%) entailed a prespecified subgroup analysis, and 1 (2.2%) was adjusted for multiple testing. Only 5 (10.9%) of the 46 subgroup findings had at least 1 subsequent pure corroboration attempt by a meta-analysis or an RCT. In all 5 cases, the corroboration attempts found no evidence of a statistically significant subgroup effect. In addition, all effect sizes from meta-analyses were attenuated toward the null. CONCLUSIONS AND RELEVANCE A minority of subgroup claims made in the abstracts of RCTs are supported by their own data (ie, a significant interaction effect). For those that have statistical support (P < .05 from an interaction test), most fail to meet other best practices for subgroup tests, including prespecification, stratified randomization, and adjustment for multiple testing. Attempts to corroborate statistically significant subgroup differences are rare; when done, the initially observed subgroup differences are not reproduced.
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Affiliation(s)
- Joshua D Wallach
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California2Meta-Research Innovation Center at Stanford (METRICS), Stanford University School of Medicine, Stanford, California
| | - Patrick G Sullivan
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California2Meta-Research Innovation Center at Stanford (METRICS), Stanford University School of Medicine, Stanford, California3Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - John F Trepanowski
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kristin L Sainani
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | | | - John P A Ioannidis
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California2Meta-Research Innovation Center at Stanford (METRICS), Stanford University School of Medicine, Stanford, California3Department of Medicine, Stanford University School of Medicine, Stanford, California4Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California6Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California
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103
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Wong GC, van Diepen S, Ainsworth C, Arora RC, Diodati JG, Liszkowski M, Love M, Overgaard C, Schnell G, Tanguay JF, Wells G, Le May M. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient. Can J Cardiol 2017; 33:1-16. [DOI: 10.1016/j.cjca.2016.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
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104
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Mulder M, Geocadin RG. Neurology of cardiopulmonary resuscitation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:593-617. [PMID: 28190437 DOI: 10.1016/b978-0-444-63599-0.00032-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This chapter aims to provide an up-to-date review of the science and clinical practice pertaining to neurologic injury after successful cardiopulmonary resuscitation. The past two decades have seen a major shift in the science and practice of cardiopulmonary resuscitation, with a major emphasis on postresuscitation neurologic care. This chapter provides a nuanced and thoughtful historic and bench-to-bedside overview of the neurologic aspects of cardiopulmonary resuscitation. A particular emphasis is made on the anatomy and pathophysiology of hypoxic-ischemic encephalopathy, up-to-date management of survivors of cardiopulmonary resuscitation, and a careful discussion on neurologic outcome prediction. Guidance to practice evidence-based clinical care when able and thoughtful, pragmatic suggestions for care where evidence is lacking are also provided. This chapter serves as both a useful clinical guide and an updated, thorough, and state-of-the-art reference on the topic for advanced students and experienced practitioners in the field.
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Affiliation(s)
- M Mulder
- Department of Critical Care and the John Nasseff Neuroscience Institute, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN, USA
| | - R G Geocadin
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine and Departments of Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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105
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Willmott AGB, Bliss A, Simpson WH, Tocker SM, Cottingham R, Maxwell NS. CAERvest® - a novel endothermic hypothermic device for core temperature cooling: safety and efficacy testing. INTERNATIONAL JOURNAL OF OCCUPATIONAL SAFETY AND ERGONOMICS 2016; 24:118-128. [PMID: 27997307 DOI: 10.1080/10803548.2016.1273640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Cooling of the body is used to treat hyperthermic individuals with heatstroke or to depress core temperature below normal for neuroprotection. A novel, chemically activated, unpowered cooling device, CAERvest®, was investigated for safety and efficacy. METHODS Eight healthy male participants (body mass 79.9 ± 1.9 kg and body fat percentage 16.1 ± 3.8%) visited the laboratory (20 °C, 40% relative humidity) on four occasions. Following 30-min rest, physiological and perceptual measures were recorded. Participants were then fitted with the CAERvest® proof of concept (PoC) or prototype 1 (P1), 2 (P2) or 3 (P3) for 60 min. Temperature, cardiovascular and perceptual measures were recorded every 5 min. After cooling, the CAERvest® was removed and the torso checked for cold-related injuries. RESULTS Temperature measures significantly (p < 0.05) reduced pre to post in all trials. Larger reductions in core and skin temperatures were observed for PoC (-0.36 ± 0.18 and -1.55 ± 0.97 °C) and P3 (-0.36 ± 0.22 and -2.47 ± 0.82 °C), compared with P1 and P2. No signs of cold-related injury were observed at any stage. CONCLUSION This study demonstrates that the CAERvest® is an effective device for reducing body temperature in healthy normothermic individuals without presence of cold injury. Further research in healthy and clinical populations is warranted.
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Affiliation(s)
- Ashley G B Willmott
- a Centre for Sport and Exercise Science and Medicine (SeSAME), Environmental Extremes Laboratory , University of Brighton , UK
| | - Alex Bliss
- a Centre for Sport and Exercise Science and Medicine (SeSAME), Environmental Extremes Laboratory , University of Brighton , UK
| | | | | | | | - Neil S Maxwell
- a Centre for Sport and Exercise Science and Medicine (SeSAME), Environmental Extremes Laboratory , University of Brighton , UK
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106
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The effect of atmosphere temperature on out-of-hospital cardiac arrest outcomes. Resuscitation 2016; 109:64-70. [DOI: 10.1016/j.resuscitation.2016.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 09/29/2016] [Accepted: 10/05/2016] [Indexed: 12/14/2022]
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107
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Sakurai A, Tagami R, Ihara S, Yamaguchi J, Sugita A, Sawada N, Komatsu T, Hori S, Kinoshita K. Development of new equipment for intra-arrest brain cooling that uses cooled oxygen in the lungs: volunteer study. Acute Med Surg 2016; 4:179-183. [PMID: 29123858 PMCID: PMC5667268 DOI: 10.1002/ams2.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 09/11/2016] [Indexed: 11/06/2022] Open
Abstract
Aims Many experimental studies have reported that intra-arrest cooling during cardiac arrest is a promising treatment to mitigate brain injury. However, there is no clinically established method for cooling the brain during cardiac arrest. We hypothesized that, as blood flow in the lungs must be very slow during cardiopulmonary resuscitation, the blood could be cooled by ventilating the lungs with cooled oxygen like a radiator, and that this cooled blood would in turn cool the brain. The aim of this study was to develop equipment to cool oxygen for this purpose and to confirm its safety on a group of volunteers. Methods We developed new equipment that cools oxygen by running it through a vinyl chloride coil submerged in a bottle of water and frozen at -80°C. Using this equipment, seven volunteers were given oxygen by mask, and their blood pressure, heart rate, and peripheral saturation of oxygen were measured. The temperature in the mask was also measured. Results This equipment was able to decrease the temperature in the mask to -5°C at the Jackson Rees circuit for an oxygen flow of 10 L/min. Among the volunteer group, vital signs were unchanged and the temperature in the mask decreased from 30.1 ± 2.6°C (mean ± standard deviation) to 15.9 ± 9.6°C. No adverse effects were observed in the volunteers after experimentation. Conclusion We successfully developed new equipment to cool oxygen and established its safety in a volunteer study.
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Affiliation(s)
- Atsushi Sakurai
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Rumi Tagami
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Shingo Ihara
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Atsunori Sugita
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Nami Sawada
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Tomohide Komatsu
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Satoshi Hori
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine Department of Acute Medicine Nihon University School of Medicine Tokyo Japan
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108
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Schock RB, Janata A, Peacock WF, Deal NS, Kalra S, Sterz F. Time to Cooling Is Associated with Resuscitation Outcomes. Ther Hypothermia Temp Manag 2016; 6:208-217. [PMID: 27906641 PMCID: PMC5144870 DOI: 10.1089/ther.2016.0026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Our purpose was to analyze evidence related to timing of cooling from studies of targeted temperature management (TTM) after return of spontaneous circulation (ROSC) after cardiac arrest and to recommend directions for future therapy optimization. We conducted a preliminary review of studies of both animals and patients treated with post-ROSC TTM and hypothesized that a more rapid cooling strategy in the absence of volume-adding cold infusions would provide improved outcomes in comparison with slower cooling. We defined rapid cooling as the achievement of 34°C within 3.5 hours of ROSC without the use of volume-adding cold infusions, with a ≥3.0°C/hour rate of cooling. Using the PubMed database and a previously published systematic review, we identified clinical studies published from 2002 through 2014 related to TTM. Analysis included studies with time from collapse to ROSC of 20–30 minutes, reporting of time from ROSC to target temperature and rate of patients in ventricular tachycardia or ventricular fibrillation, and hypothermia maintained for 20–24 hours. The use of cardiopulmonary bypass as a cooling method was an exclusion criterion for this analysis. We compared all rapid cooling studies with all slower cooling studies of ≥100 patients. Eleven studies were initially identified for analysis, comprising 4091 patients. Two additional studies totaling 609 patients were added based on availability of unpublished data, bringing the total to 13 studies of 4700 patients. Outcomes for patients, dichotomized into faster and slower cooling approaches, were determined using weighted linear regression using IBM SPSS Statistics software. Rapid cooling without volume-adding cold infusions yielded a higher rate of good neurological recovery than slower cooling methods. Attainment of a temperature below 34°C within 3.5 hours of ROSC and using a cooling rate of more than 3°C/hour appear to be beneficial.
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Affiliation(s)
- Robert B Schock
- 1 Sid Wolvek Research Center , Life Recovery Systems HD, LLC, Kinnelon, New Jersey
| | - Andreas Janata
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
| | - W Frank Peacock
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | - Nathan S Deal
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | | | - Fritz Sterz
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
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109
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Fazel Bakhsheshi M, Wang Y, Keenliside L, Lee TY. A new approach to selective brain cooling by a Ranque-Hilsch vortex tube. Intensive Care Med Exp 2016; 4:32. [PMID: 27686339 PMCID: PMC5042908 DOI: 10.1186/s40635-016-0102-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 09/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background Target temperature management is the single most effective intervention and the gold standard in post-resuscitation care today. However, cooling the whole body below 33–34 °C can cause severe complications. Therefore, developing a selective brain cooling (SBC) approach which can be initiated early to induce rapid cooling and maintain the target temperature over 12–24 h before slowly rewarming brain temperature by itself alone would be advantageous. Vortex tubes are simple mechanical devices generating cold air from a stream of compressed air without applied chemical or energy. This study investigated whether blowing cooled air from a vortex tube into the nasal cavities is safe and effective to selectively reduce and maintain before slowly rewarming brain temperature back to normal temperature. Methods Experiments were conducted on ten juvenile pigs. Body temperature was measured using an esophageal and a rectal temperature probe while brain temperature with an intraparenchymal thermocouple probe. Cerebral blood flow (CBF) was measured with CT perfusion. Results Brain temperature dropped below 34 °C within 30–40 min while a brain-esophageal temperature difference greater than 3 °C was maintained over 6 h. There was no evidence of nasal or nasopharynx mucosal swelling, necrosis, or hemorrhage on MRI examination. CBF first decreased and then stabilized together with brain temperature before increasing to the baseline level during rewarming. Conclusions SBC was accomplished by blowing cold air from a vortex tube into the nasal cavities. Due to its portability, the method can be used continuously in resuscitated patients in both in- and out-of-hospital situations without interruption.
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Affiliation(s)
- Mohammad Fazel Bakhsheshi
- Imaging Program, Lawson Health Research Institute, London, ON, Canada. .,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada.
| | - Yong Wang
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada
| | - Lynn Keenliside
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada
| | - Ting-Yim Lee
- Imaging Program, Lawson Health Research Institute, London, ON, Canada.,Imaging Research Laboratories, Robarts Research Institute, 1151 Richmond Street North, London, ON, N6A 5B7, Canada.,Department of Medical Imaging and Biophysics, The University of Western Ontario, London, ON, Canada
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110
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Bonaventura J, Alan D, Vejvoda J, Honek J, Veselka J. History and current use of mild therapeutic hypothermia after cardiac arrest. Arch Med Sci 2016; 12:1135-1141. [PMID: 27695505 PMCID: PMC5016592 DOI: 10.5114/aoms.2016.61917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/05/2015] [Indexed: 11/17/2022] Open
Abstract
In spite of many years of development and implementation of pre-hospital advanced life support programmes, the survival rate of out-of-hospital cardiac arrest (OHCA) used to be very poor. Neurologic injury from cerebral hypoxia is the most common cause of death in patients with OHCA. In the past two decades, post-resuscitation care has developed many new concepts aimed at improving the neurological outcome and survival rate of patients after cardiac arrest. Systematic post-cardiac arrest care after the return of spontaneous circulation, including induced mild therapeutic hypothermia (TH) in selected patients, is aimed at significantly improving rates of long-term neurologically intact survival. This review summarises the history and current knowledge in the field of mild TH after OHCA.
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Affiliation(s)
- Jiří Bonaventura
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - David Alan
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jiri Vejvoda
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Jakub Honek
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, 2 Medical School, Charles University, University Hospital Motol, Prague, Czech Republic
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Chava R, Zviman M, Raghavan MS, Halperin H, Maqbool F, Geocadin R, Quinones-Hinojosa A, Kolandaivelu A, Rosen BA, Tandri H. Rapid Induction of Therapeutic Hypothermia Using Transnasal High Flow Dry Air. Ther Hypothermia Temp Manag 2016; 7:50-56. [PMID: 27635468 DOI: 10.1089/ther.2016.0016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Early induction of therapeutic hypothermia (TH) is recommended in out-of-hospital cardiac arrest (CA); however, currently no reliable methods exist to initiate cooling. We investigated the effect of high flow transnasal dry air on brain and body temperatures in adult porcine animals. Adult porcine animals (n = 23) under general anesthesia were subject to high flow of transnasal dry air. Mouth was kept open to create a unidirectional airflow, in through the nostrils and out through the mouth. Brain, internal jugular, and aortic temperatures were recorded. The effect of varying airflow rate and the air humidity (0% or 100%) on the temperature profiles were recorded. The degree of brain cooling was measured as the differential temperature from baseline. A 10-minute exposure of high flow dry air caused rapid cooling of brain and gradual cooling of the jugular and the aortic temperatures in all animals. The degree of brain cooling was flow dependent and significantly higher at higher airflow rates (0.8°C ± 0.3°C, 1.03°C ± 0.6°C, and 1.3°C ± 0.7°C for 20, 40, and 80 L, respectively, p < 0.05 for all comparisons). Air temperature had minimal effect on the brain cooling over 10 minutes with similar decrease in temperature at 4°C and 30°C. At a constant flow rate (40 LPM) and temperature, the degree of cooling over 10 minutes during dry air exposure was significantly higher compared to humid air (100% saturation) (1.22°C ± 0.35°C vs. 0.21°C ± 0.12°C, p < 0.001). High flow transnasal dry air causes flow dependent cooling of the brain and the core temperatures in intubated porcine animals. The mechanism of cooling appears to be evaporation of nasal mucus as cooling is mitigated by humidifying the air. This mechanism may be exploited to initiate TH in CA.
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Affiliation(s)
- Raghuram Chava
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Menekhem Zviman
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Madhavan Srinivas Raghavan
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Henry Halperin
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Farhan Maqbool
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Romergryko Geocadin
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Alfredo Quinones-Hinojosa
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Aravindan Kolandaivelu
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Benjamin A Rosen
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Harikrishna Tandri
- Division of Cardiology, Departments of Neuroanesthesia and Neurosurgery, The Johns Hopkins University School of Medicine , Baltimore, Maryland
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112
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Prehospital therapeutic hypothermia after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Am J Emerg Med 2016; 34:2209-2216. [PMID: 27658332 DOI: 10.1016/j.ajem.2016.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/01/2016] [Accepted: 09/03/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The effectiveness and safety of the infusion of ice-cold fluids for prehospital hypothermia in cardiac arrest victims are unclear. This study assessed its effects in adult victims of out-of-hospital cardiac arrest. METHODS An online search of PubMed and Cochrane Library databases was performed. Cooling methods were limited to ice-cold fluid perfusion. Randomized controlled trials were included in this review. The main outcomes were body temperature at hospital arrival, survival to hospital discharge, neurological recovery, incidence of pulmonary edema, and the rate of rearrest. RESULTS Among 1155 citations, 5 studies were included in this meta-analysis. The pooled analysis of these studies revealed no differences in survival to hospital discharge, favorable neurological outcomes, and incidence of pulmonary edema between the treatment group and control group. There were significant differences in body temperature at hospital arrival (I2 = 0.0%, χ2 = 2.58, MD = -0.760, 95% confidence interval = -0.938 to -0.581, P < .001) and the rate of rearrest (I2 = 0.0%, χ2 = 0.69, 95% confidence interval = 1.109 to 1.479, P = .031). CONCLUSIONS Prehospital therapeutic hypothermia induced by intravenous infusion of ice-cold fluids in patients with out-of-hospital cardiac arrest decreased body temperature at hospital arrival but did not improve survival to hospital discharge and favorable neurological outcomes. Ice-cold fluid infusion did not increase the incidence of pulmonary edema but increased the incidence of rearrests.
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113
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Kim T, Paine MG, Meng H, Xiaodan R, Cohen J, Jinka T, Zheng H, Cranford JA, Neumar RW. Combined intra- and post-cardiac arrest hypothermic-targeted temperature management in a rat model of asphyxial cardiac arrest improves survival and neurologic outcome compared to either strategy alone. Resuscitation 2016; 107:94-101. [PMID: 27521473 DOI: 10.1016/j.resuscitation.2016.07.232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 06/29/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
AIM Post-cardiac arrest hypothermic-targeted temperature management (HTTM) improves outcomes in preclinical cardiac arrest studies. However, inadequate understanding of the mechanisms and therapeutic windows remains a barrier to optimization. We tested the hypothesis that combined intra- and post-cardiac arrest HTTM provides a synergistic outcome benefit compared to either strategy alone. METHODS Rats subjected to 8-min asphyxial cardiac arrest were block randomized to 4 treatment groups (n=12/group): NTTM) normothermic-targeted temperature management; 1-24 HTTM) HTTM initiated 1h post-ROSC and maintained for 24h; Intra-1 HTTM) HTTM initiated at CPR onset and maintained for 1h; and Intra-24 HTTM) HTTM initiated at CPR onset and maintained for 24h. HTTM was induced by nasopharyngeal cooling and maintained using an automated temperature regulation system. Target temperature range was 36.5-37.5°C for NTTM and 32.0-34.0°C for HTTM. Post-arrest neurologic function score (NFS) was measured daily, and rats surviving 72h were euthanized for histological analysis of neurodegeneration. RESULTS Target brain temperature was achieved 7.8±3.3min after initiating intra-arrest cooling. The survival rate was 42%, 50%, 50%, and 92% in the NTTM, 1-24 HTTM, Intra-1 HTTM, and Intra-24 HTTM groups, respectively (p<0.05, Intra-24 group vs. all other groups). The rate of survival with good neurologic function (NFS≥450) was 33% in the Intra-24 HTTM group vs. 0% in all other groups (mid p<0.05). Hippocampal CA1 sector neurodegeneration was significantly reduced in the Intra-24 HTTM group compared to all other groups (p<0.05). CONCLUSION Combined intra- and post-cardiac arrest HTTM has greater outcome benefits than either strategy alone.
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Affiliation(s)
- Taeyun Kim
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Emergency Medicine, Gyeongsang National University Hospital, Republic of Korea
| | - Michael G Paine
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - He Meng
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Ren Xiaodan
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Jacob Cohen
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Tulasi Jinka
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Huiyong Zheng
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Robert W Neumar
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States.
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 734] [Impact Index Per Article: 91.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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115
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Grave MS, Sterz F, Nürnberger A, Fykatas S, Gatterbauer M, Stättermayer AF, Zajicek A, Malzer R, Sebald D, van Tulder R. Safety and feasibility of the RhinoChill immediate transnasal evaporative cooling device during out-of-hospital cardiopulmonary resuscitation: A single-center, observational study. Medicine (Baltimore) 2016; 95:e4692. [PMID: 27559978 PMCID: PMC5400345 DOI: 10.1097/md.0000000000004692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We investigated feasibility and safety of the RhinoChill (RC) transnasal cooling system initiated before achieving a protected airway during cardiopulmonary resuscitation (CPR) in a prehospital setting.In out-of-hospital cardiac arrest (OHCA), transnasal evaporative cooling was initiated during CPR, before a protected airway was established and continued until either the patient was declared dead, standard institutional systemic cooling methods were implemented or cooling supply was empty. Patients were monitored throughout the hypothermia period until either death or hospital discharge. Clinical assessments and relevant adverse events (AEs) were documented over this period of time.In total 21 patients were included. Four were excluded due to user errors or meeting exclusion criteria. Finally, 17 patients (f = 6; mean age 65.5 years, CI95%: 57.7-73.4) were analyzed. Device-related AEs, like epistaxis or nose whitening, occurred in 2 patients. They were mild and had no consequence on the patient's outcome. According to the field reports of the emergency medical services (EMS) personnel, no severe technical problems occurred by using the RC device that led to a delay or the impairment of quality of the CPR.Early application of the RC device, during OHCA is feasible, safe, easy to handle, and does not delay or hinder CPR, or establishment of a secure intubation. For efficacy and further safety data additional studies will be needed.
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Affiliation(s)
- Marie-Sophie Grave
- Department of Emergency Medicine, Medical University of Vienna
- University Hospital St. Pölten, Karl-Landsteiner Medical University, Lower Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna
- Correspondence: Fritz Sterz, Univ Kl f Notfallmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20/6D, 1090 Wien, Austria (e-mail: )
| | | | | | | | - Albert Friedrich Stättermayer
- Department of Internal Medicine III, Divison of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Dieter Sebald
- Wiener Berufsrettung, Municipal Ambulance Service, Vienna
| | - Raphael van Tulder
- Department of Emergency Medicine, Medical University of Vienna
- Wiener Berufsrettung, Municipal Ambulance Service, Vienna
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116
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Aibiki M, Chiang MC, Muengtaweepongsa S, Pothiawala S, Huang CH. Asian Targeted Temperature Management Task Panel Report. Ther Hypothermia Temp Manag 2016; 7:16-23. [PMID: 27403966 DOI: 10.1089/ther.2016.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the fields of emergency and critical care, targeted temperature management has become a critical issue and particularly popular in clinical practices throughout Asia. As more research is carried out, evidence and concepts about targeted temperature management continue to evolve. Areas of interest include new 2015 resuscitation guidelines, temperature management in pediatrics, and integrated care and neurological monitoring for cardiac arrest patients. The Asian Targeted Temperature Management task panel includes colleagues from various Asian countries and allows them to exchange experiences in a professional environment. Some of the key issues include optimal therapeutic hypothermia temperature for postcardiac arrest syndrome pursuant to 2015 guidelines, an integral approach to postcardiac arrest syndrome with hemodynamic monitoring and stabilization, roles of percutaneous coronary intervention and extracorporeal membrane oxygenation, and temperature management for neonatal hypoxic-ischemic encephalopathy. Panel experts reviewed all of the aforementioned issues and discussed the feasibility and effectiveness of targeted temperature management based on the Asian population. These discussions can expand the perspectives with regard to applying targeted temperature management all over the world.
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Affiliation(s)
- Mayuki Aibiki
- 1 Department of Emergency Medicine, Ehime University , Tohon City, Japan
| | - Ming-Chou Chiang
- 2 Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine , Taoyuan, Taiwan
| | - Sombat Muengtaweepongsa
- 3 Division of Neurology, Department of Medicine, Thammasat University , Pathumthani, Thailand
| | - Sohil Pothiawala
- 4 Department of Emergency Medicine, Singapore General Hospital , Singapore, Singapore
| | - Chien-Hua Huang
- 5 Department of Emergency Medicine, National Taiwan University Hospital , Taipei, Taiwan
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117
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Kim YM, Park KN, Choi SP, Lee BK, Park K, Kim J, Kim JH, Chung SP, Hwang SO. Part 4. Post-cardiac arrest care: 2015 Korean Guidelines for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016; 3:S27-S38. [PMID: 27752644 PMCID: PMC5052921 DOI: 10.15441/ceem.16.130] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/19/2016] [Accepted: 03/19/2016] [Indexed: 11/23/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Kyungil Park
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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118
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Stratil P, Holzer M. Is hypothermia indicated during cardiopulmonary resuscitation and after restoration of spontaneous circulation? Curr Opin Crit Care 2016; 22:212-7. [DOI: 10.1097/mcc.0000000000000299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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119
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Kohlhauer M, Berdeaux A, Kerber RE, Micheau P, Ghaleh B, Tissier R. Liquid Ventilation for the Induction of Ultrafast Hypothermia in Resuscitation Sciences: A Review. Ther Hypothermia Temp Manag 2016; 6:63-70. [DOI: 10.1089/ther.2015.0024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthias Kohlhauer
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Alain Berdeaux
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Richard E. Kerber
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Philippe Micheau
- Department of Mechanical Engineering, Université de Sherbrooke, Sherbrooke, Canada
| | - Bijan Ghaleh
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
| | - Renaud Tissier
- Inserm, Unité 955, Equipe 03, Créteil, France
- Université Paris Est, UMR_S955, DHU A-TVB, UPEC, Créteil, France
- Université Paris Est, École Nationale Vétérinaire d'Alfort, Maisons-Alfort Cedex, France
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120
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Mendibil A, Jost D, Thiry A, Garcia D, Trichereau J, Frattini B, Dang-Minh P, Maurin O, Margerin S, Domanski L, Tourtier JP. Laboratory study on the kinetics of the warming of cold fluids-A hot topic. Anaesth Crit Care Pain Med 2016; 35:337-342. [PMID: 27157476 DOI: 10.1016/j.accpm.2015.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 10/09/2015] [Accepted: 12/15/2015] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In case of mild therapeutic hypothermia after an out-of-hospital cardiac arrest, several techniques could limit the cold fluid rewarming during its perfusion. We aimed to evaluate cold fluid temperature evolution and to identify the factors responsible for rewarming in order to suggest a prediction model of temperature evolution. EQUIPMENT AND METHODS This was a laboratory experimental study. We measured temperature at the end of the infusion line tubes (ILT). A 500ml saline bag at 4°C was administered at 15 and 30ml/min, with and without cold packs applied to the cold fluid bag or to the ILT. Cold fluid temperature was integrated in a linear mixed model. Then we performed a mathematical modelization of the thermal transfer across the ILT. RESULTS The linear mixed model showed that the mean temperature of the cold fluid was 1°C higher (CI 95%: [0.8-1.2]) with an outflow rate of 15 versus 30ml/min (P<0.001). Similarly, the mean temperature of the cold fluid was 0.7°C higher (CI 95%: [0.53-0.9]) without cold pack versus with cold packs (P<0.001). Mathematical modelization of the thermal transfer across the ILT suggested that the cold fluid warming could be reduced by a shorter and a wider ILT. As expected, use of CP has also a noticeable influence on warning reduction. The combination of multiple parameters working against the rewarming of the solution should enable the infusion of a solute with retained caloric properties. CONCLUSIONS By limiting this "ILT effect," the volume required for inducing mild therapeutic hypothermia could be reduced, leading to a safer and a more efficient treatment.
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Affiliation(s)
- Alexandre Mendibil
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France.
| | - Daniel Jost
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Aurélien Thiry
- Fire engineering section, Physics and fire engineering division at the Central Laboratory of the Prefecture of Police of Paris (LCPP), 39 bis, rue de Dantzig, 75015 Paris, France
| | - Delphine Garcia
- Fire engineering section, Physics and fire engineering division at the Central Laboratory of the Prefecture of Police of Paris (LCPP), 39 bis, rue de Dantzig, 75015 Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Olga Maurin
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Sylvie Margerin
- Paris Fire Brigade Emergency Medical Department, BPIB, BSPP, 1, avenue Guy Moquet, 94460 Valenton, France
| | - Laurent Domanski
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
| | - Jean-Pierre Tourtier
- Paris Fire Brigade Emergency Medical Department, BMU, BSPP, 1, place Jules Renard, 75017 Paris, France
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Fukuda T. Targeted temperature management for adult out-of-hospital cardiac arrest: current concepts and clinical applications. J Intensive Care 2016; 4:30. [PMID: 27123306 PMCID: PMC4847228 DOI: 10.1186/s40560-016-0139-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/04/2016] [Indexed: 11/25/2022] Open
Abstract
Targeted temperature management (TTM) (primarily therapeutic hypothermia (TH)) after out-of-hospital cardiac arrest (OHCA) has been considered effective, especially for adult-witnessed OHCA with a shockable initial rhythm, based on pathophysiology and on several clinical studies (especially two randomized controlled trials (RCTs) published in 2002). However, a recently published large RCT comparing TTM at 33 °C (TH) and TTM at 36 °C (normothermia) showed no advantage of 33 °C over 36 °C. Thus, this RCT has complicated the decision to perform TH after cardiac arrest. The results of this RCT are sometimes interpreted fever control alone is sufficient to improve outcomes after cardiac arrest because fever control was not strictly performed in the control groups of the previous two RCTs that showed an advantage for TH. Although this may be possible, another interpretation that the optimal target temperature for TH is much lower than 33 °C may be also possible. Additionally, there are many points other than target temperature that are unknown, such as the optimal timing to initiate TTM, the period between OHCA and initiating TTM, the period between OHCA and achieving the target temperature, the duration of maintaining the target temperature, the TTM technique, the rewarming method, and the management protocol after rewarming. RCTs are currently underway to shed light on several of these underexplored issues. In the present review, we examine how best to perform TTM after cardiac arrest based on the available evidence.
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Affiliation(s)
- Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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122
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Arrich J, Holzer M, Havel C, Warenits A, Herkner H. Pre-hospital versus in-hospital initiation of cooling for survival and neuroprotection after out-of-hospital cardiac arrest. Cochrane Database Syst Rev 2016; 3:CD010570. [PMID: 26978162 PMCID: PMC6353090 DOI: 10.1002/14651858.cd010570.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Targeted temperature management (also known under 'therapeutic hypothermia', 'induced hypothermia'", or 'cooling') has been shown to be beneficial for neurological outcome in patients who have had successful resuscitation from sudden cardiac arrest, but it remains unclear when this intervention should be initiated. OBJECTIVES To assess the effects of pre-hospital initiation of cooling on survival and neurological outcome in comparison to in-hospital initiation of cooling for adults with pre-hospital cardiac arrest. SEARCH METHODS We searched CENTRAL, MEDLINE, EMBASE, CINAHL, BIOSIS, and three trials registers from inception to 5 March 2015, and carried out reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) in adults with out-of-hospital cardiac arrest comparing cooling in the pre-hospital setting to in-hospital cooling. Our primary outcomes were survival and neurological outcome; our secondary outcomes were adverse events, quality of life, and length of stay in the intensive care unit (ICU) and in the hospital. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. MAIN RESULTS We included seven RCTs (2369 participants randomized) on the induction of pre-hospital cooling in comparison to in-hospital cooling. There was considerable methodological heterogeneity and risk of bias mainly due to deficits in the administration of cooling, therefore we refrained from pooling the results for survival and neurological outcome and we presented the results for each study separately. Adverse events were rare: based on four studies with 1713 adults pre-hospital induction of cooling may increase the risk of cardiac re-arrests. Risk of bias within the seven individual studies was generally moderate. Overall the quality of the evidence was very low. This was mainly driven by inconsistency and low precision. AUTHORS' CONCLUSIONS Currently, there is no convincing evidence to clearly delineate beneficial or harmful effects of pre-hospital induction of cooling in comparison to in-hospital induction of cooling. This conclusion is based on very low quality evidence.
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Affiliation(s)
- Jasmin Arrich
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Michael Holzer
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Christof Havel
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Alexandra‐Maria Warenits
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustria1090
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Harris S, Bansbach J, Dietrich I, Kalbhenn J, Schmutz A. RhinoChill(®)-more than an "ice-cream headache (1)" serious adverse event related to transnasal evaporative cooling. Resuscitation 2016; 103:e5-e6. [PMID: 26980347 DOI: 10.1016/j.resuscitation.2016.01.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Sarah Harris
- Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Joachim Bansbach
- Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Irene Dietrich
- Department of Radiology, Freiburg University Medical Center, Freiburg, Germany
| | - Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Center, Freiburg, Germany.
| | - Axel Schmutz
- Department of Anaesthesiology and Critical Care Medicine, Freiburg University Medical Center, Freiburg, Germany
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Abstract
Mild therapeutic hypothermia of 32-35°C improved neurologic outcomes in outside hospital cardiac arrest survivor. Furthermore, in experimental studies on infarcted model and pilot studies on conscious patients with acute myocardial infarction, therapeutic hypothermia successfully reduced infarct size and microvascular resistance. Therefore, mild therapeutic hypothermia has received an attention as a promising solution for reduction of infarction size after acute myocardial infarction which are not completely solved despite of optimal reperfusion therapy. Nevertheless, the results from randomized clinical trials failed to prove the cardioprotective effects of therapeutic hypothermia or showed beneficial effects only in limited subgroups. In this article, we reviewed rationale for therapeutic hypothermia and possible mechanisms from previous studies, effective methods for clinical application to the patients with acute myocardial infarction, lessons from current clinical trials and future directions.
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Affiliation(s)
- In Sook Kang
- Department of Internal Medicine, Green Hospital, Seoul, Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ikeno Fumiaki
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Wook Bum Pyun
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea.
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Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O'Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S84-145. [PMID: 26472860 DOI: 10.1161/cir.0000000000000273] [Citation(s) in RCA: 241] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Donnino MW, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, Lang E, Cocchi MN, Xanthos T, Callaway CW, Soar J. Temperature Management After Cardiac Arrest. Resuscitation 2016; 98:97-104. [DOI: 10.1016/j.resuscitation.2015.09.396] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lampe JW, Bratinov G, Weiland TR, Illindala U, Berg RA, Becker LB. Volume infusion cooling increases end-tidal carbon dioxide and results in faster and deeper cooling during intra-cardiopulmonary resuscitation hypothermia induction. Intensive Care Med Exp 2015; 3:37. [PMID: 26715581 PMCID: PMC4695470 DOI: 10.1186/s40635-015-0073-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/20/2015] [Indexed: 11/22/2022] Open
Abstract
Background Intra-arrest hypothermia induction may provide more benefit than inducing hypothermia after return of spontaneous circulation. However, little is understood about the interaction between patient physiology and hypothermia induction technology choice during ongoing chest compressions. Methods After 10 min of untreated ventricular fibrillation, mechanical chest compressions were provided for 60 min (100 CPM, 1.25" deep) in 26 domestic swine (30.5 ± 1.7 kg) with concurrent hypothermia induction using one of eight cooling methods. Four cooling methods included volume infusion with cold saline or an ice particulate slurry through the femoral vein or carotid artery (volume infusion cooling group, VC); three included cooling via an intra-vascular heat exchange catheter, nasal cooling, or surface ice bags (no volume cooling group, NVC); and the other was a control group with no cooling (no cooling group, NC). Physiological monitoring included end-tidal carbon dioxide, aortic pressure, right atrial pressure, brain temperature, esophageal temperature, and rectal temperature. Results During cardiopulmonary resuscitation (CPR), the volume infusion cooling group cooled faster and to lower temperatures than the other groups (VC vs. NVC or NC; ∆T = −5.6 vs. −2.1 °C or −0.6 °C; p < 0.01). The aortic pressure and right atrial pressure were higher in the volume cooling group than the other groups (VC vs. NVC or NC; AOP = 23.6 vs. 16.7 mmHg or 14.7 mmHg; p < 0.02). End-tidal carbon dioxide measurements during CPR were also higher in the volume cooling group (VC vs. NVC; EtCO2 = 23.4 vs. 13.1 mmHg; p < 0.05). Intra-corporeal temperature gradients larger than 3 °C were created by volume cooling during ongoing chest compressions. Conclusions Volume infusion cooling significantly altered physiology relative to other cooling methods during ongoing chest compressions. Volume cooling led to faster cooling rates, lower temperatures, higher end-tidal carbon dioxide levels, and higher central vascular pressures. IACUC protocol numbers: UPenn (803178), CHOP (997)
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Affiliation(s)
- Joshua W Lampe
- The Feinstein Institute for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA.
| | - George Bratinov
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Theodore R Weiland
- Department of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | | | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Lance B Becker
- The Feinstein Institute for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, 11030, USA.
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Ultrarapid Induction of Hypothermia Using Continuous Automated Peritoneal Lavage With Ice-Cold Fluids: Final Results of the Cooling for Cardiac Arrest or Acute ST-Elevation Myocardial Infarction Trial. Crit Care Med 2015. [PMID: 26196354 DOI: 10.1097/ccm.0000000000001158] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Hypothermia (32-34 °C) can mitigate ischemic brain injury, and some evidence suggests that it can reduce infarct size in acute myocardial infarction and acute ischemic stroke. For some indications, speed of cooling may be crucial in determining efficacy. We performed a multicenter prospective intervention study to test an ultrarapid cooling technology, the Velomedix Automated Peritoneal Lavage System using ice-cold fluids continuously circulating through the peritoneal cavity to rapidly induce and maintain hypothermia in comatose patients after cardiac arrest and a small number of awake patients with acute myocardial infarction. DESIGN Multicenter prospective intervention study. SETTING Intensive care- and coronary care units of multiple tertiary referral centers. MEASUREMENTS AND MAIN RESULTS Access to the peritoneal cavity was gained using a modified blunt dilating instrument, followed by catheter placement. Patients were cooled to a temperature of 32.5 °C, maintained for 24 hours (cardiac arrest) or 3 hours (acute myocardial infarction) followed by controlled rewarming. Forty-nine patients were enrolled, and 46 patients completed treatment. One placement was unsuccessful (abdominal wall not breached), two patients were ultimately not cooled, and only safety data are reported. Average catheter insertion time was 2.3 minutes. Mean time to temperature less than 33 °C was 10.4 minutes (average cooling rate, 14 °C/hr). Median infarct size in patients who had coronary interventions was 16% of LV. No cases of stent thrombosis occurred. Survival in cardiac arrest patients with initial rhythm of ventricular tachycardia/ventricular fibrillation was 56%, of whom 82 had a complete neurologic recovery. This compares favorably to outcomes from previous studies. CONCLUSION Automated peritoneal lavage system is a safe and ultrarapid method to induce and maintain hypothermia, which appears feasible in cardiac arrest patients and awake patients with acute myocardial infarction. The shivering response appeared to be delayed and much reduced with this technology, diminishing metabolic disorders associated with cooling and minimizing sedation requirement. Our data suggest that ultrarapid cooling could prevent subtle neurologic damage compared with slower cooling. This will need to be confirmed in direct comparative studies.
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Hypothermic Total Liquid Ventilation Is Highly Protective Through Cerebral Hemodynamic Preservation and Sepsis-Like Mitigation After Asphyxial Cardiac Arrest. Crit Care Med 2015; 43:e420-30. [PMID: 26110489 DOI: 10.1097/ccm.0000000000001160] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Total liquid ventilation provides ultrafast and potently neuro- and cardioprotective cooling after shockable cardiac arrest and myocardial infarction in animals. Our goal was to decipher the effect of hypothermic total liquid ventilation on the systemic and cerebral response to asphyxial cardiac arrest using an original pressure- and volume-controlled ventilation strategy in rabbits. DESIGN Randomized animal study. SETTING Academic research laboratory. SUBJECTS New Zealand Rabbits. INTERVENTIONS Thirty-six rabbits were submitted to 13 minutes of asphyxia, leading to cardiac arrest. After resumption of spontaneous circulation, they underwent either normothermic life support (control group, n = 12) or hypothermia induced by either 30 minutes of total liquid ventilation (total liquid ventilation group, n = 12) or IV cold saline (conventional cooling group, n = 12). MEASUREMENTS AND MAIN RESULTS Ultrafast cooling with total liquid ventilation (32 °C within 5 min in the esophagus) dramatically attenuated the post-cardiac arrest syndrome regarding survival, neurologic dysfunction, and histologic lesions (brain, heart, kidneys, liver, and lungs). Final survival rate achieved 58% versus 0% and 8% in total liquid ventilation, control, and conventional cooling groups (p < 0.05), respectively. This was accompanied by an early preservation of the blood-brain barrier integrity and cerebral hemodynamics as well as reduction in the immediate reactive oxygen species production in the brain, heart, and kidneys after cardiac arrest. Later on, total liquid ventilation also mitigated the systemic inflammatory response through alteration of monocyte chemoattractant protein-1, interleukin-1β, and interleukin-8 transcripts levels compared with control. In the conventional cooling group, cooling was achieved more slowly (32 °C within 90-120 min in the esophagus), providing none of the above-mentioned systemic or organ protection. CONCLUSIONS Ultrafast cooling by total liquid ventilation limits the post-cardiac arrest syndrome after asphyxial cardiac arrest in rabbits. This protection involves an early limitation in reactive oxidative species production, blood-brain barrier disruption, and delayed preservation against the systemic inflammatory response.
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Kudenchuk PJ, Sandroni C, Drinhaus HR, Böttiger BW, Cariou A, Sunde K, Dworschak M, Taccone FS, Deye N, Friberg H, Laureys S, Ledoux D, Oddo M, Legriel S, Hantson P, Diehl JL, Laterre PF. Breakthrough in cardiac arrest: reports from the 4th Paris International Conference. Ann Intensive Care 2015; 5:22. [PMID: 26380990 PMCID: PMC4573754 DOI: 10.1186/s13613-015-0064-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/18/2015] [Indexed: 02/08/2023] Open
Abstract
Jean-Luc Diehl The French Intensive Care Society organized on 5th and 6th June 2014 its 4th "Paris International Conference in Intensive Care", whose principle is to bring together the best international experts on a hot topic in critical care medicine. The 2014 theme was "Breakthrough in cardiac arrest", with many high-quality updates on epidemiology, public health data, pre-hospital and in-ICU cares. The present review includes short summaries of the major presentations, classified into six main chapters: Epidemiology of CA Pre-hospital management Post-resuscitation management: targeted temperature management Post-resuscitation management: optimizing organ perfusion and metabolic parameters Neurological assessment of brain damages Public healthcare.
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Affiliation(s)
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy.
| | - Hendrik R Drinhaus
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University of Koeln, Cologne, Germany.
| | - Alain Cariou
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris, France.
- Paris Descartes University and Sorbonne Paris Cité-Medical School and INSERM U970 (Team 4), Cardiovascular Research Center, European Georges Pompidou Hospital, Paris, France.
| | - Kjetil Sunde
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Surgical Intensive Care Unit Ullevål, Oslo University Hospital, Oslo, Norway.
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Vienna General Hospital, Medical University Vienna, Vienna, Austria.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Laboratoire de Recherche Experimentale, Erasme Hospital, Brussels, Belgium.
| | - Nicolas Deye
- Medical Intensive Care Unit, AP-HP, Lariboisière University Hospital, Inserm U942, Paris, France.
| | - Hans Friberg
- Anaesthesiology and Intensive Care Medicine, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Steven Laureys
- Coma Science Group, Cyclotron Research Centre, University of Liège and Liège 2 Department of Neurology, University Hospital of Liège, Liège, Belgium.
| | - Didier Ledoux
- Coma Science Group, Cyclotron Research Centre, University of Liège and Department of Intensive Care Medicine, University Hospital of Liège, Liège, Belgium.
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, CHUV-University Hospital, Lausanne, Switzerland.
| | - Stéphane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, Le Chesnay, France.
| | - Philippe Hantson
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Jean-Luc Diehl
- Medical Intensive Care Unit, AP-HP, European Georges Pompidou Hospital, Paris Descartes University and Sorbonne Paris Cité-Medical School, Paris, France.
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels, Brussels, Belgium.
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Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465-82. [PMID: 26472996 PMCID: PMC4959439 DOI: 10.1161/cir.0000000000000262] [Citation(s) in RCA: 1013] [Impact Index Per Article: 112.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Schmid B, Fritz H, Fink K, Eichwede F, Storm C, Elste T, Rössler M, Koberne F, Busch HJ. Präklinische transnasale Kühlung während der Reanimation in Deutschland. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0043-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cardiac arrest and therapeutic hypothermia. Trends Cardiovasc Med 2015; 26:337-44. [PMID: 26603661 DOI: 10.1016/j.tcm.2015.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 11/22/2022]
Abstract
Therapeutic hypothermia for patients who remain comatose following resuscitation from a cardiac arrest improves both survival and neurologic outcomes. Although this therapy has been incorporated into the guidelines for routine post-resuscitation care and has been in clinical use for over a decade, significant questions and controversies remain. In this review, we discuss these questions in the context of the current evidence and provide a practical framework to help guide clinicians.
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Donnino MW, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, Lang E, Cocchi MN, Xanthos T, Callaway CW, Soar J. Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Circulation 2015; 132:2448-56. [PMID: 26434495 DOI: 10.1161/cir.0000000000000313] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
For more than a decade, mild induced hypothermia (32 °C-34 °C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33 °C or 36 °C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32 °C and 36 °C for at least 24 hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document.
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Bucher J, Koyfman A. Does Initiation of Therapeutic Hypothermia in the Out-of-Hospital Environment Improve Neurologic Outcomes? Ann Emerg Med 2015; 66:379-80. [DOI: 10.1016/j.annemergmed.2014.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Indexed: 11/28/2022]
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Soar J, Callaway CW, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, Andersen LW, Berg KM, Sandroni C, Lin S, Lavonas EJ, Golan E, Alhelail MA, Chopra A, Cocchi MN, Cronberg T, Dainty KN, Drennan IR, Fries M, Geocadin RG, Gräsner JT, Granfeldt A, Heikal S, Kudenchuk PJ, Lagina AT, Løfgren B, Mhyre J, Monsieurs KG, Mottram AR, Pellis T, Reynolds JC, Ristagno G, Severyn FA, Skrifvars M, Stacey WC, Sullivan J, Todhunter SL, Vissers G, West S, Wetsch WA, Wong N, Xanthos T, Zelop CM, Zimmerman J. Part 4: Advanced life support. Resuscitation 2015; 95:e71-120. [DOI: 10.1016/j.resuscitation.2015.07.042] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW The 2010 Cardiopulmonary Resuscitation (CPR) Guidelines recommended therapeutic hypothermia for postcardiac arrest syndrome as a beneficial and effective treatment. However, the optimal temperature, method, onset, duration and rewarming rate, and therapeutic window remain unknown. RECENT FINDINGS Recent animal studies have shown that the sooner cooling is initiated after cardiac arrest, the better the outcome. Induction of hypothermia during cardiac arrest before return of spontaneous circulation (ROSC) (intra-arrest cooling) enhances its efficacy. In 2010, the Pre-ROSC IntraNasal Cooling Effectiveness (PRINCE) study and our clinical study of intra-arrest cooling concluded that intra-arrest cooling before ROSC was likely to have neurological benefits while protecting the myocardium for patients with out-of-hospital cardiac arrest. SUMMARY One of the most significant advances in CPR treatment in the past decade is therapeutic hypothermia. Although post-ROSC cooling has been shown to improve neurological outcome for patients with out-of-hospital cardiac arrest, intra-arrest cooling during CPR is likely to protect the myocardium from reperfusion injury and enhance neurological benefits.
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Vargas M, Sutherasan Y, Servillo G, Pelosi P. What is the proper target temperature for out-of-hospital cardiac arrest? Best Pract Res Clin Anaesthesiol 2015; 29:425-34. [PMID: 26670814 DOI: 10.1016/j.bpa.2015.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 12/21/2022]
Abstract
The implementation of target temperature management (TTM) or therapeutic hypothermia has been demonstrated in several major studies to be an effective neuroprotective strategy in postresuscitation care after cardiac arrest. Although several landmark studies found the promising results of lower targeted temperature (32-34 °C) in terms of survival and neurological outcomes, recent evidence showed no difference in either survival or long-term neurological outcome when compared with higher targeted temperature (36 °C). Thus, recent data suggest that avoiding hyperpyrexia, rather than cooling "per se," may be considered the main therapeutic target to avoid secondary brain damage after out-of-hospital cardiac arrest. Many questions are still debated about the exact protocol of TTM to be used, including whether temperature control is more beneficial than standard of care without active temperature control, the optimal cooling temperature, patient selection, and duration of cooling. The aim of this review article was to discuss the physiology of hypothermia, available cooling methods, and current evidence about the optimal target temperature and timing of hypothermia.
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Affiliation(s)
- Maria Vargas
- Department of Neuroscience and Reproductive and Odontostomatological, Sciences, University of Naples "Federico II", Naples, Italy.
| | - Yuda Sutherasan
- Division of Pulmonary and Critical Care Unit, Department of Medicine, Ramathibodi Hospital, Mahidol University 270 RAMA VI Road, Bangkok 10400, Thailand.
| | - Giuseppe Servillo
- Department of Neuroscience and Reproductive and Odontostomatological, Sciences, University of Naples "Federico II", Naples, Italy.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics IRCCS AOU San Martino-IST, Largo Rosanna Benzi 8, Genoa 16131, Italy.
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140
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Hunter BR, Ellender TJ. Targeted temperature management in emergency medicine: current perspectives. Open Access Emerg Med 2015; 7:69-77. [PMID: 27147892 PMCID: PMC4806809 DOI: 10.2147/oaem.s71279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Landmark trials in 2002 showed that therapeutic hypothermia (TH) after out-of-hospital cardiac arrest due to ventricular tachycardia or ventricular fibrillation resulted in improved likelihood of good neurologic recovery compared to standard care without TH. Since that time, TH has been frequently instituted in a wide range of cardiac arrest patients regardless of initial heart rhythm. Recent evidence has evaluated how, when, and to what degree TH should be instituted in cardiac arrest victims. We outline early evidence, as well as recent trials, regarding the use of TH or targeted temperature management in these patients. We also provide evidence-based suggestions for the institution of targeted temperature management/TH in a variety of emergency medicine settings.
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Affiliation(s)
- Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA; Department of Critical Care Medicine, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
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Islam S, Hampton-Till J, Watson N, Mannakkara NN, Hamarneh A, Webber T, Magee N, Abbey L, Jagathesan R, Kabir A, Sayer J, Robinson N, Aggarwal R, Clesham G, Kelly P, Gamma R, Tang K, Davies JR, Keeble TR. Early targeted brain COOLing in the cardiac CATHeterisation laboratory following cardiac arrest (COOLCATH). Resuscitation 2015; 97:61-7. [PMID: 26410565 DOI: 10.1016/j.resuscitation.2015.09.386] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/11/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory. METHODS 70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge. RESULTS There was no difference in time to reach ≤34 °C between Rhinochill and Blanketrol (Tympanic ≤34 °C, 75 vs. 107 mins; p=0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 °C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%. CONCLUSION In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.
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Affiliation(s)
- Shahed Islam
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - James Hampton-Till
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK
| | - Noel Watson
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | | | - Ashraf Hamarneh
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Teresa Webber
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Neil Magee
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Lucy Abbey
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Rohan Jagathesan
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Alamgir Kabir
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Jeremy Sayer
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Nicholas Robinson
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Rajesh Aggarwal
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Gerald Clesham
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Paul Kelly
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Reto Gamma
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Kare Tang
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - John R Davies
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK.
| | - Thomas R Keeble
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK.
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Rab T, Kern KB, Tamis-Holland JE, Henry TD, McDaniel M, Dickert NW, Cigarroa JE, Keadey M, Ramee S. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol 2015; 66:62-73. [PMID: 26139060 DOI: 10.1016/j.jacc.2015.05.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/28/2015] [Accepted: 05/05/2015] [Indexed: 12/14/2022]
Abstract
Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. Although there is an American College of Cardiology Foundation/American Heart Association Class I recommendation for performing immediate angiography and percutaneous coronary intervention (when indicated) in patients with ST-segment elevation myocardial infarction, no guidelines exist for patients without ST-segment elevation. Early introduction of mild therapeutic hypothermia is an established treatment goal. However, there are no established guidelines for risk stratification of patients for cardiac catheterization and possible percutaneous coronary intervention, particularly in patients who have unfavorable clinical features in whom procedures may be futile and affect public reporting of mortality. An algorithm is presented to improve the risk stratification of these severely ill patients with an emphasis on consultation and evaluation of patients prior to activation of the cardiac catheterization laboratory.
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Affiliation(s)
- Tanveer Rab
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | | | - Timothy D Henry
- Division of Cardiology, Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael McDaniel
- Division of Cardiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Neal W Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joaquin E Cigarroa
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Matthew Keadey
- Division of Emergency Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen Ramee
- Structural and Valvular Heart Disease Program, Ochsner Medical Center, New Orleans, Louisiana
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Cerebral Blood Flow Threshold Is Higher for Membrane Repolarization Than for Depolarization and Is Lowered by Intraischemic Hypothermia in Rats*. Crit Care Med 2015; 43:e350-5. [DOI: 10.1097/ccm.0000000000001095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wavra T, Laux C, Guanci MM, Figueroa SA, Brophy GM, Kurczewski L, Livesay SL. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2015; 5:177-81. [DOI: 10.1089/ther.2015.29002.mkb] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Chris Laux
- Harborview Medical Center, Seattle, Washington
| | | | - Stephen A. Figueroa
- Division of Neurocritical Care, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Lisa Kurczewski
- Department of Pharmacy Services, Virginia Commonwealth University Health System, Richmond, Virginia
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Huang FY, Huang BT, Wang PJ, Zuo ZL, Heng Y, Xia TL, Gui YY, Lv WY, Zhang C, Liao YB, Liu W, Chen M, Zhu Y. The efficacy and safety of prehospital therapeutic hypothermia in patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 2015; 96:170-9. [PMID: 26300235 DOI: 10.1016/j.resuscitation.2015.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND The benefit of therapeutic hypothermia (TH) to patients suffering out-of-hospital cardiac arrest (OHCA) has been well established. However, the effect of prehospital cooling remains unclear. We aimed to investigate the efficacy and safety of prehospital TH for OHCA patients by conducting a systematic review of randomised controlled trials (RCTs). METHODS The MEDLINE, EMbase and CENTRAL databases were searched for publications from inception to April 2015. RCTs that compared cooling with no cooling in a prehospital setting among adults with OHCA were eligible for inclusion. Random- and fixed-effect models were used depending on inter-study heterogeneity. RESULTS Eight trials that recruited 2379 participants met the inclusion criteria. Prehospital TH was significantly associated with a lower temperature at admission (mean difference (MD) -0.94; 95% confidence interval (CI) -1.06 to -0.82). However, survival upon admission (Risk ratio (RR) 1.01, 95%CI 0.98-1.04), survival at discharge (RR 1.02, 95%CI 0.91-1.14), in-hospital survival (RR 1.05, 95%CI 0.92-1.19) and good neurological function recovery (RR 1.06, 95% CI 0.91-1.23) did not differ between the TH-treated and non-treated groups. Prehospital cooling increased the incidence of recurrent arrest (RR 1.23, 95%CI 1.02-1.48) and decreased the PH at admission (MD -0.04, 95%CI -0.07 to -0.02). Pulmonary oedema did not differ between the arms (RR 1.02, 95%CI 0.67-1.57). None of the potentially controversial issues (cooling methods, time of inducing TH, the proportion of continuing cooling in hospital, actual prehospital infusion volume and primary cardiac rhythms) affected the efficacy. CONCLUSION Evidence does not support the administration of prehospital TH to patients with OHCA.
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Affiliation(s)
- Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Peng-Ju Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi-Liang Zuo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Heng
- Department of Family Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tian-Li Xia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Yue Gui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen-Yu Lv
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.
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Zughaft DJL, Hyllén S, Harnek J, Nozohoor S, Bjursten H, Götberg M. Safety, Feasibility, and Hemodynamic Effects of Mild Hypothermia in Transcatheter Aortic Valve Replacement: The TAVR-CHILL Trial. Ther Hypothermia Temp Manag 2015. [PMID: 26222725 DOI: 10.1089/ther.2015.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The safety, feasibility, and hemodynamic effects of mild hypothermia (MH) induced by transnasal cooling were studied in transcatheter aortic valve replacement (TAVR). MH is a common therapy following cardiac arrest and seems to have favorable effects in myocardial infarction and on hemodynamic stability. In TAVR, hemodynamic instability is common during rapid pacing. Twenty subjects undergoing TAVR were randomized 1:1 to hypothermia or normothermia. Hemodynamic endpoints were mean arterial blood pressure and required dosage of vasoactive and inotropic drugs. Patients were followed up at 6 months. All patients in the MH group (n=10) reached the target temperature of 34°C before first rapid pacing. Tympanic and urinary bladder temperature remained significantly lower in the MH group during the procedure. No adverse effects of cooling were observed. Mean arterial pressure was higher in the MH group (90±20 mm Hg) than in the control group (71±13 mm Hg) at the start of the procedure, at first rapid pacing (94±19 vs. 80±16 mm Hg), and at balloon aortic valvuloplasty (90±17 vs. 73±14 mm Hg). Less norepinephrine was administered to the hypothermia group. Transnasal cooling during TAVR was safe and well tolerated. We observed a more stable hemodynamic profile in the MH group, indicated by higher blood pressure and lower levels of vasoactive drugs required. A larger study of patients with severe ventricular dysfunction is required to more comprehensively investigate the hemodynamic effects of transnasal cooling in TAVR.
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Affiliation(s)
- David J L Zughaft
- 1 Department of Coronary Heart Disease, Skane University Hospital, Lund University , Lund, Sweden .,2 Department of Cardiology, Skane University Hospital , Lund University, Lund, Sweden
| | - Snejana Hyllén
- 3 Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University , Lund, Sweden
| | - Jan Harnek
- 1 Department of Coronary Heart Disease, Skane University Hospital, Lund University , Lund, Sweden .,2 Department of Cardiology, Skane University Hospital , Lund University, Lund, Sweden
| | - Shahab Nozohoor
- 3 Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University , Lund, Sweden
| | - Henrik Bjursten
- 3 Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University , Lund, Sweden
| | - Matthias Götberg
- 1 Department of Coronary Heart Disease, Skane University Hospital, Lund University , Lund, Sweden .,2 Department of Cardiology, Skane University Hospital , Lund University, Lund, Sweden
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147
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Abstract
Since their introduction over 40 years ago, paramedics have been trained to deliver select advanced life support interventions in the community with the goal of reducing morbidity and mortality from cardiovascular disease and trauma. The ensuing decades witnessed a great deal of interest in paramedic care, with an exponential growth in prehospital resuscitation research. As part of the CJEM series on emergency medical services (EMS), we review recent prehospital research in out-of-hospital cardiac arrest and discuss how, in a novel departure from the origins of EMS, prehospital research is beginning to influence in-hospital care. We discuss emerging areas of study related to cardiopulmonary resuscitation (CPR) quality, therapeutic hypothermia, termination of resuscitation, and the use of end-tidal carbon dioxide measurement, as well as the subtle ripple effects that prehospital research is having on the broader understanding of the management of these critically ill patients.
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148
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Abstract
Targeted temperature management has an established role in treating the post-cardiac arrest syndrome after out-of-hospital cardiac arrest with an initial rhythm of ventricular tachycardia/ventricular fibrillation. There is less certain benefit if the initial rhythm is pulseless electrical activity/asystole or for in-hospital cardiac arrest. Targeted temperature management may have a role as salvage modality for conditions causing intracranial hypertension, such as traumatic brain injury, hepatic encephalopathy, intracerebral hemorrhage, and acute stroke. There is variable evidence for its use early in these disorders to minimize secondary neurologic injury.
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Affiliation(s)
- John McGinniss
- Pulmonary, Allergy & Critical Care Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, 839 West Gates Building, Philadelphia, PA 19104, USA.
| | - Peter Marshall
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520-8057, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520-8057, USA
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149
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Taccone FS. Intra-arrest-cooling PRO. BMC Emerg Med 2015. [PMCID: PMC4481094 DOI: 10.1186/1471-227x-15-s1-a11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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150
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Abstract
Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.
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Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh, Suite 10028, Forbes Tower, Pittsburgh, PA 15260, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan Street Northeast, Suite 420, Grand Rapids, MI 49503, USA.
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