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Kuroda Y, Kawakita K. Targeted temperature management for postcardiac arrest syndrome. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Rittenberger J, Kurz M, Polderman KH. Therapeutic Hypothermia in Postcardiac Arrest. Ther Hypothermia Temp Manag 2017; 7:184-187. [PMID: 29027885 DOI: 10.1089/ther.2017.29036.jjr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jon Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Michael Kurz
- 2 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
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Choi W, Kwon SC, Lee WJ, Weon YC, Choi B, Lee H, Park ES, Ahn R. Feasibility and Safety of Mild Therapeutic Hypothermia in Poor-Grade Subarachnoid Hemorrhage: Prospective Pilot Study. J Korean Med Sci 2017; 32:1337-1344. [PMID: 28665071 PMCID: PMC5494334 DOI: 10.3346/jkms.2017.32.8.1337] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/24/2017] [Indexed: 01/10/2023] Open
Abstract
Therapeutic hypothermia (TH) improves the neurological outcome in patients after cardiac arrest and neonatal hypoxic brain injury. We studied the safety and feasibility of mild TH in patients with poor-grade subarachnoid hemorrhage (SAH) after successful treatment. Patients were allocated randomly to either the TH group (34.5°C) or control group after successful clipping or coil embolization. Eleven patients received TH for 48 hours followed by 48 hours of slow rewarming. Vasospasm, delayed cerebral ischemia (DCI), functional outcome, mortality, and safety profiles were compared between groups. We enrolled 22 patients with poor-grade SAH (Hunt & Hess Scale 4, 5 and modified Fisher Scale 3, 4). In the TH group, 10 of 11 (90.9%) patients had a core body temperature of < 36°C for > 95% of the 48-hour treatment period. Fewer patients in the TH than control group (n = 11, each) had symptomatic vasospasms (18.1% vs. 36.4%, respectively) and DCI (36.3% vs. 45.6%, respectively), but these differences were not statistically significant. At 3 months, 54.5% of the TH group had a good-to-moderate functional outcome (0-3 on the modified Rankin Scale [mRS]) compared with 9.0% in the control group (P = 0.089). Mortality at 1 month was 36.3% in the control group compared with 0.0% in the TH group (P = 0.090). Mild TH is feasible and can be safely used in patients with poor-grade SAH. Additionally, it may reduce the risk of vasospasm and DCI, improving the functional outcomes and reducing mortality. A larger randomized controlled trial is warranted.
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Affiliation(s)
- Wookjin Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soon Chan Kwon
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Won Joo Lee
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Cheol Weon
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byungho Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hyeji Lee
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Choi KE, Park B, Moheet AM, Rosen A, Lahiri S, Rosengart A. Systematic Quality Assessment of Published Antishivering Protocols. Anesth Analg 2017; 124:1539-1546. [PMID: 27622717 DOI: 10.1213/ane.0000000000001571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Shivering is a common side effect of targeted temperature modulation and general anesthesia. Antishivering strategies often employ a stepwise approach involving both pharmacological and physical interventions. However, approaches to treat shivering are often empiric and vary widely across care environments. We evaluated the quality of published antishivering protocols and guidelines with respect to methodological rigor, reliability, and consistency of recommendations.Using 4 medical databases, we identified 4027 publications that addressed shivering therapy, and excluded 3354 due to lack of relevance. After applying predefined eligibility criteria with respect to minimal protocol standards, 18 protocols/guidelines remained. Each was assessed using a modified Appraisal of Guidelines for Research and Evaluation II (mAGREE II) instrument containing 23 quality items within 6 domains (maximal score 23). Among 18 protocols/guidelines, only 3 incorporated systematically reviewed recommendations, whereas 15 merely targeted practice standardization. Fifteen of 18 protocols/guidelines addressed shivering during therapeutic cooling in which skin counterwarming and meperidine were most commonly cited. However, their mAGREE II scores were within the lowest tertile (1 to 7 points) and the median for all 18 protocols was 5. The quality domains most commonly absent were stakeholder involvement, rigor of development, and editorial independence. Three of 18 protocols/guidelines addressed postanesthetic antishivering. Of these, the American Society of Anesthesiologists guidelines recommending forced-air warming and meperidine received the highest mAGREE II score (14 points), whereas the remaining 2 recommendations had low scores (<5 points).Current published antishivering protocols/guidelines lack methodological rigor, reliability, and strength, and even the highest scoring of the 18 protocols/guidelines fulfilled only 60% of quality items. To be consistent with evidence-based protocol/guideline development processes, future antishivering treatment algorithms should increase methodological rigor and transparency.
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Affiliation(s)
- Ko-Eun Choi
- From the Departments of *Neurology, †Neurosurgery, ‡Pharmacy, and §Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
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Tommasi E, Lazzeri C, Bernardo P, Sori A, Chiostri M, Gensini GF, Valente S. Cooling techniques in mild hypothermia after cardiac arrest. J Cardiovasc Med (Hagerstown) 2017; 18:459-466. [DOI: 10.2459/jcm.0000000000000130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nakashima R, Hifumi T, Kawakita K, Okazaki T, Egawa S, Inoue A, Seo R, Inagaki N, Kuroda Y. Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest. Circ J 2017; 81:427-439. [PMID: 28239054 DOI: 10.1253/circj.cj-16-1006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.
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Affiliation(s)
- Ryuta Nakashima
- Department of Emergency and Critical Care Medicine, Oita City Medical Association's Almeida Memorial Hospital
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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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Picchi A, Valente S, Gensini G. Therapeutic hypothermia in the intensive cardiac care unit. J Cardiovasc Med (Hagerstown) 2016; 16:363-71. [PMID: 25022927 DOI: 10.2459/jcm.0000000000000108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Therapeutic hypothermia has demonstrated to improve both survival and neurological outcome in patients who experienced an out-of-hospital cardiac arrest. Nevertheless, many aspects of its clinical application are still controversial. Current guidelines recommend to cool patients who survive a cardiac arrest due to either ventricular fibrillation or ventricular tachycardia, whereas the beneficial effect of lowering body temperature in nonshockable rhythms is still questionable due to the lack of randomized controlled trial involving this subgroup of patients. Although therapeutic hypothermia is often begun before hospital arrival, the optimal time to start cooling is still a matter of debate. Furthermore, different methods are available to low body temperature, but no direct comparisons are available to establish which device performs better than others, and a combination of external and endovascular cooling is usually preferred. The present review is aimed at summarizing the available evidence supporting the use in clinical practice of mild hypothermia in comatose survivors from cardiac arrest and at evaluating its adverse events and their treatment.
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Affiliation(s)
- Andrea Picchi
- aDepartment of Cardiology, Misericordia Hospital, Grosseto bDepartment of Medical and Surgical Critical Care, University of Florence, Florence, Italy
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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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Affiliation(s)
- Kees H Polderman
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (K.H.P.); University of Pittsburgh Medical Center, Pittsburgh, PA (K.H.P.); University of Texas Health Science Center at Houston (J.V.); University of Texas Medical Branch at Galveston (J.V.); and University General Hospital, Houston, TX (J.V.).
| | - Joseph Varon
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (K.H.P.); University of Pittsburgh Medical Center, Pittsburgh, PA (K.H.P.); University of Texas Health Science Center at Houston (J.V.); University of Texas Medical Branch at Galveston (J.V.); and University General Hospital, Houston, TX (J.V.)
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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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Polderman K, Lockhart K, Badjatia N. Temperature management in neurological and neurosurgical intensive care units. Ther Hypothermia Temp Manag 2015; 4:62-6. [PMID: 24905837 DOI: 10.1089/ther.2014.1504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Abstract
PURPOSE OF REVIEW Fever is common in the ICU among patients with severe brain injury. Fever has been consistently shown to exacerbate brain injuries in animal models and has been consistently associated with poor outcome in human studies. However, whether fever control improves outcome and the ideal means of fever control remain unknown. This review will address recent literature on the impact of fever on severe brain injury and on interventions to maintain normothermia. RECENT FINDINGS Current guidelines generally recommend maintenance of normothermia after brain injury but have scant recommendations on methods to do this. Observational trials have continued to demonstrate the association between fever and poor outcome after severe brain injury. Recent trials have shown the efficacy of more aggressive approaches to fever reduction, whereas a large randomized trial showed the relative ineffectiveness of acetaminophen alone for fever control. Several studies have also described the impact of fever and of fever control on brain physiology. SUMMARY The value of therapeutic normothermia in the neurocritical care unit (NCCU) is increasingly accepted, yet prospective trials that demonstrate a functional benefit to patients are lacking.
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Polderman KH, Varon J. We should not abandon therapeutic cooling after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:130. [PMID: 25029533 PMCID: PMC4056164 DOI: 10.1186/cc13817] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Long-Tounsel R, Wilson J, Adams C, Reising DL. Urban and Suburban Hospital System Implementation of Multipoint Access Targeted Temperature Management in Postcardiac Arrest Patients. Ther Hypothermia Temp Manag 2014. [DOI: 10.1089/ther.2013.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ruby Long-Tounsel
- Department of Emergency Medicine, Methodist Hospitals, Gary, Indiana
| | - Jessica Wilson
- Department of Nursing Development, Methodist Hospitals, Gary, Indiana
| | - Constance Adams
- Department of Cardiovascular Care, Methodist Hospitals, Gary, Indiana
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Ferreira Da Silva IR, Frontera JA. Targeted Temperature Management in Survivors of Cardiac Arrest. Cardiol Clin 2013; 31:637-55, ix. [DOI: 10.1016/j.ccl.2013.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Massetti M, Gaudino M, De Paulis S, Scapigliati A, Cavaliere F. Extracorporeal membrane oxygenation for resuscitation and cardiac arrest management. Heart Fail Clin 2013; 10:S85-93. [PMID: 24262356 DOI: 10.1016/j.hfc.2013.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This article reviews the potential application of extracorporeal membrane oxygenation (ECMO) technology to cardiopulmonary resuscitation for in and out-of-hospital cardiac arrest and discusses the current evidence on the subject. The possible strategies for organ protection during ECMO and the concept of ECMO networks are also reviewed.
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Affiliation(s)
- Massimo Massetti
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, Catholic University, L.go Gemelli 1, 00168 Rome, Italy
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Piastra M, Cavallaro F, Genovese O, De Luca D, Biasucci DG, De Sanctis R, Pietrini D, Conti G. Double cooling for pericardial tamponade and cardiac arrest after rewarming in neonatal asphyxia. Resuscitation 2013; 84:e83-4. [PMID: 23528679 DOI: 10.1016/j.resuscitation.2013.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 03/10/2013] [Accepted: 03/13/2013] [Indexed: 10/27/2022]
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