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Binda DD, Logan CM, Rosales V, Nozari A, Rendon LF. Targeted Temperature Management After Cardiac Arrest in COVID-19 Patients. Ther Hypothermia Temp Manag 2024; 14:130-143. [PMID: 37582193 DOI: 10.1089/ther.2023.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
There is a paucity of evidence regarding the utility of targeted temperature management (TTM) in COVID-19 patients who suffer cardiac arrest. This systematic review and meta-analysis aimed to use the available data of how temperature predicts outcomes in COVID-19 patients and the association between active cooling and outcomes in non-COVID-19 cardiac arrest patients to give recommendations for the utility of TTM in COVID-19 survivors of cardiac arrest. The PubMed, Embase, and Web of Science databases were queried in August 2022 for two separate searches: (1) temperature as a predictor of clinical outcomes in COVID-19 and (2) active cooling after return of spontaneous circulation (ROSC) in non-COVID-19. Forest plots were generated to summarize the results. Of the 4209 abstracts screened, none assessed the target population of TTM in COVID-19 victims of cardiac arrest. One retrospective cohort study evaluated hyperthermia in critically ill COVID-19 patients, two retrospective cohort studies evaluated hypothermia in septic COVID-19 patients, and 20 randomized controlled trials evaluated active cooling in non-COVID-19 patients after ROSC. Risk of death was higher in COVID-19 patients who presented with hyperthermia (risk ratio [RR] = 1.87) or hypothermia (RR = 1.77; p < 0.001). In non-COVID-19 victims of cardiac arrest, there was no significant difference in mortality (RR = 0.94; p = 0.098) or favorable neurological outcome (RR = 1.05; p = 0.41) with active cooling after ROSC. Further studies are needed to evaluate TTM in COVID-19 victims of cardiac arrest. However, given the available evidence that hyperthermia or hypothermia in COVID-19 patients is associated with increased mortality as well as our findings suggesting limited utility for active cooling in non-COVID-19 cardiac arrest patients, we posit that TTM to normothermia (core body temperature ∼37°C) would most likely be optimal for the best outcomes in COVID-19 survivors of cardiac arrest.
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Affiliation(s)
- Dhanesh D Binda
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Connor M Logan
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Victoria Rosales
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ala Nozari
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Luis F Rendon
- Department of Anesthesiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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2
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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024; 48:341-355. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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Miao B, Skaar JR, O'Hara M, Post A, Kelly T, Abella BS. A Systematic Literature Review to Assess Fever Management and the Quality of Targeted Temperature Management in Critically Ill Patients. Ther Hypothermia Temp Manag 2024; 14:68-79. [PMID: 37219898 DOI: 10.1089/ther.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
Targeted temperature management (TTM) has been proposed to reduce mortality and improve neurological outcomes in postcardiac arrest and other critically ill patients. TTM implementation may vary considerably among hospitals, and "high-quality TTM" definitions are inconsistent. This systematic literature review in relevant critical care conditions evaluated the approaches to and definitions of TTM quality with respect to fever prevention and the maintenance of precise temperature control. Current evidence on the quality of fever management associated with TTM in cardiac arrest, traumatic brain injury, stroke, sepsis, and critical care more generally was examined. Searches were conducted in Embase and PubMed (2016 to 2021) following PRISMA guidelines. In total, 37 studies were identified and included, with 35 focusing on postarrest care. Frequently-reported TTM quality outcomes included the number of patients with rebound hyperthermia, deviation from target temperature, post-TTM body temperatures, and number of patients achieving target temperature. Surface and intravascular cooling were used in 13 studies, while one study used surface and extracorporeal cooling and one study used surface cooling and antipyretics. Surface and intravascular methods had comparable rates of achieving target temperature and maintaining temperature. A single study showed that patients with surface cooling had a lower incidence of rebound hyperthermia. This systematic literature review largely identified cardiac arrest literature demonstrating fever prevention with multiple TTM approaches. There was substantial heterogeneity in the definitions and delivery of quality TTM. Further research is required to define quality TTM across multiple elements, including achieving target temperature, maintaining target temperature, and preventing rebound hyperthermia.
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Affiliation(s)
| | | | | | - Andrew Post
- Trinity Life Sciences, Waltham, Massachusetts, USA
| | - Tim Kelly
- Becton Dickinson, Franklin Lakes, New Jersey, USA
| | - Benjamin S Abella
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jiang L, Bian Y, Liu W, Zheng W, Zheng J, Li C, Lv R, Pan Y, Zheng Z, Wang M, Sang S, Pan C, Wang C, Liu R, Cheng K, Zhang J, Ma J, Chen Y, Xu F. TREATMENT OF COMATOSE SURVIVORS OF IN-HOSPITAL CARDIAC ARREST WITH EXTENDED ENDOVASCULAR COOLING METHOD FOR 72 H: A PROPENSITY SCORE-MATCHED ANALYSIS. Shock 2024; 61:204-208. [PMID: 38010311 DOI: 10.1097/shk.0000000000002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Aims: Targeted temperature management is recommended for at least 24 h in comatose survivors of in-hospital cardiac arrest (IHCA) after the return of spontaneous circulation; however, whether an extension for 72 h leads to better neurological outcomes is uncertain. Methods: We included data from the Qilu Hospital of Shandong University between July 20, 2019, and June 30, 2022. Unconscious patients who had return of spontaneous circulation lasting >20 consecutive min and received endovascular cooling (72 h) or normothermia treatment were compared in terms of survival-to-discharge and favorable neurological survival. Propensity score matching was used to formulate balanced 1:3 matched patients. Results: In total, 2,084 patients were included. Sixteen patients received extended endovascular cooling and 48 matched controls received normothermia therapy. Compared with the normothermia group, patients who received prolonged endovascular cooling had a higher survival-to-discharge rate. However, good neurological outcomes did not differ significantly. Before matching, Cox regression analysis, using mortality as the event, showed that extended endovascular cooling independently affected the survival of IHCA patients. Conclusions: Among comatose patients who had been resuscitated from IHCA, the use of endovascular cooling for 72 h might confer a benefit on survival-to-discharge.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Shaowei Sang
- Shandong University Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, China
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Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2024; 149:e254-e273. [PMID: 38108133 DOI: 10.1161/cir.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
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Chiu PY, Chung CC, Tu YK, Tseng CH, Kuan YC. Therapeutic hypothermia in patients after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Am J Emerg Med 2023; 71:182-189. [PMID: 37421815 DOI: 10.1016/j.ajem.2023.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/18/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) with therapeutic hypothermia (TH) has been used to improve neurological outcomes in patients after cardiac arrest; however, several trials have reported conflicting results regarding its effectiveness. This systematic review and meta-analysis assessed whether TH was associated with better survival and neurological outcomes after cardiac arrest. METHOD We searched online databases for relevant studies published before May 2023. Randomized controlled trials (RCTs) comparing TH and normothermia in post-cardiac-arrest patients were selected. Neurological outcomes and all-cause mortality were assessed as the primary and secondary outcomes, respectively. A subgroup analysis according to initial electrocardiography (ECG) rhythm was performed. RESULT Nine RCTs (4058 patients) were included. The neurological prognosis was significantly better in patients with an initial shockable rhythm after cardiac arrest (RR = 0.87, 95% confidence interval [CI] = 0.76-0.99, P = 0.04), especially in those with earlier TH initiation (<120 min) and prolonged TH duration (≥24 h). However, the mortality rate after TH was not lower than that after normothermia (RR = 0.91, 95% CI = 0.79-1.05). In patients with an initial nonshockable rhythm, TH did not provide significantly more neurological or survival benefits (RR = 0.98, 95% CI = 0.93-1.03 and RR = 1.00, 95% CI = 0.95-1.05, respectively). CONCLUSION Current evidence with a moderate level of certainty suggests that TH has potential neurological benefits for patients with an initial shockable rhythm after cardiac arrest, especially in those with faster TH initiation and longer TH maintenance.
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Affiliation(s)
- Po-Yun Chiu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of General Medicine, Department of Medical Education, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chen-Chih Chung
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan
| | - Chien-Hua Tseng
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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7
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Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar J, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Pediatrics 2023; 151:189896. [PMID: 36325925 DOI: 10.1542/peds.2022-060463] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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Matsumoto S, Kuno T, Mikami T, Takagi H, Ikeda T, Briasoulis A, Bortnick AE, Sims D, Katz JN, Jentzer J, Bangalore S, Alviar CL. Effect of cooling methods and target temperature on outcomes in comatose patients resuscitated from cardiac arrest: Systematic review and network meta-analysis of randomized trials. Am Heart J 2023; 256:73-84. [PMID: 36372248 DOI: 10.1016/j.ahj.2022.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been recommended after cardiac arrest (CA), however the specific temperature targets and cooling methods (intravascular cooling (IVC) versus surface cooling (SC)) remain uncertain. METHODS PUBMED and EMBASE were searched until October 8, 2022 for randomized clinical trials (RCTs) investigating the efficacy of TTM after CA. The randomized treatment arms were categorized into the following 6 groups: 31..C to 33..C IVC, 31..C to 33..C SC, 34..C to 36..C IVC, 34..C to 36..C SC, strict normothermia or fever prevention (Strict NT or FP), and standard of care without TTM (No-TTM). The primary outcome was neurological recovery. P-score was used to rank the treatments, where a larger value indicates better performance. RESULTS We identified 15 RCTs, involving 5,218 patients with CA. Compared to No-TTM as the reference, the other therapeutic options significantly improved neurological outcomes (vs No-TTM; 31..C to 33.. C IVC RR = 0.67, 95% CI 0.54 to 0.83; 31..C to 33..C SC RR = 0.73, 95% CI 0.61 to 0.87; 34..C to 36.. C IVC RR = 0.66, 95% CI 0.51 to 0.86; 34..C to 36..C SC: RR = 0.73, 0.59 to 0.90; Strict NT or FP: RR = 0.75, 95% CI 0.62 to 0.90). Overall, 31-33..C IVC had the highest probability to be the best therapeutic option to improve outcomes (the ranking P-score of 0.836). As a subgroup analysis, the ranking P-score showed that IVC might be a better cooling method compared to SC (IVC vs SC P-score: 0.960 vs 0.670). CONCLUSIONS Hypothermia (31..C to 36..C IVC and SC) and active normothermia (Strict-NT and Strict-FP) were associated with better neurological outcomes compared to No-TTM, with IVC having a greater probability of being the better cooling method than SC.
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Affiliation(s)
- Shingo Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY.
| | | | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takanori Ikeda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Anna E Bortnick
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Daniel Sims
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Jason N Katz
- Division of Cardiovascular Medicine, Duke University, Durham, NC
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sripal Bangalore
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
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10
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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11
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Ong YKG, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Palazzo FS, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2022; 146:e483-e557. [PMID: 36325905 DOI: 10.1161/cir.0000000000001095] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Stefano Palazzo F, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2022; 181:208-288. [PMID: 36336195 DOI: 10.1016/j.resuscitation.2022.10.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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Sandroni C, Natalini D, Nolan JP. Temperature control after cardiac arrest. Crit Care 2022; 26:361. [PMID: 36434649 PMCID: PMC9700892 DOI: 10.1186/s13054-022-04238-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/27/2022] Open
Abstract
Most of the patients who die after cardiac arrest do so because of hypoxic-ischemic brain injury (HIBI). Experimental evidence shows that temperature control targeted at hypothermia mitigates HIBI. In 2002, one randomized trial and one quasi-randomized trial showed that temperature control targeted at 32-34 °C improved neurological outcome and mortality in patients who are comatose after cardiac arrest. However, following the publication of these trials, other studies have questioned the neuroprotective effects of hypothermia. In 2021, the largest study conducted so far on temperature control (the TTM-2 trial) including 1900 adults comatose after resuscitation showed no effect of temperature control targeted at 33 °C compared with normothermia or fever control. A systematic review of 32 trials published between 2001 and 2021 concluded that temperature control with a target of 32-34 °C compared with fever prevention did not result in an improvement in survival (RR 1.08; 95% CI 0.89-1.30) or favorable functional outcome (RR 1.21; 95% CI 0.91-1.61) at 90-180 days after resuscitation. There was substantial heterogeneity across the trials, and the certainty of the evidence was low. Based on these results, the International Liaison Committee on Resuscitation currently recommends monitoring core temperature and actively preventing fever (37.7 °C) for at least 72 h in patients who are comatose after resuscitation from cardiac arrest. Future studies are needed to identify potential patient subgroups who may benefit from temperature control aimed at hypothermia. There are no trials comparing normothermia or fever control with no temperature control after cardiac arrest.
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Affiliation(s)
- Claudio Sandroni
- grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy ,grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart. Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS. L.go F, Vito 1, 00168 Rome, Italy
| | - Daniele Natalini
- grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy
| | - Jerry P. Nolan
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, CV4 7AL UK ,grid.416091.b0000 0004 0417 0728Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG UK
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Lüsebrink E, Binzenhöfer L, Kellnar A, Scherer C, Schier J, Kleeberger J, Stocker TJ, Peterss S, Hagl C, Stark K, Petzold T, Fichtner S, Braun D, Kääb S, Brunner S, Theiss H, Hausleiter J, Massberg S, Orban M. Targeted Temperature Management in Postresuscitation Care After Incorporating Results of the TTM2 Trial. J Am Heart Assoc 2022; 11:e026539. [DOI: 10.1161/jaha.122.026539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrest still accounts for a substantial proportion of cardiovascular related deaths and is associated with a tremendous risk of neurological injury and, among the few survivors, poor quality of life. Critical determinants of survival and long‐term functional status after cardiac arrest are timely initiation of cardiopulmonary resuscitation and use of an external defibrillator for patients with a shockable rhythm. Outcomes are still far from satisfactory, despite ongoing efforts to improve cardiac arrest response systems, as well as elaborate postresuscitation algorithms. Targeted temperature management at the wide range between 32 °C and 36 °C has been one of the main therapeutic strategies to improve neurological outcome in postresuscitation care. This recommendation has been mainly based on 2 small randomized trials that were published 20 years ago. Most recent data derived from the TTM2 (Targeted Hypothermia Versus Targeted Normothermia After Out‐of‐Hospital Cardiac Arrest) trial, which included 1861 patients, challenge this strategy. It showed no benefit of targeted hypothermia at 33 °C over normothermia at 36 °C to 37.5 °C with fever prevention. Because temperature management at lower temperatures also correlated with an increased risk of side effects without any benefit in the TTM2 trial, a modification of the guidelines with harmonizing temperature management to normothermia might be necessary.
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Affiliation(s)
- Enzo Lüsebrink
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Leonhard Binzenhöfer
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Antonia Kellnar
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Clemens Scherer
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Johannes Schier
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Jan Kleeberger
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Thomas J. Stocker
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik Klinikum der Universität München Munich Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik Klinikum der Universität München Munich Germany
| | - Konstantin Stark
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Tobias Petzold
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stephanie Fichtner
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Daniel Braun
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stefan Kääb
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stefan Brunner
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Hans Theiss
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Jörg Hausleiter
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Steffen Massberg
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Martin Orban
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
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Javanbakht M, Mashayekhi A, Hemami MR, Branagan-Harris M, Keeble TR, Yaghoubi M. Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England. PHARMACOECONOMICS - OPEN 2022; 6:549-562. [PMID: 35503202 PMCID: PMC9283555 DOI: 10.1007/s41669-022-00333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been shown to improve neurological outcomes and survival in patients resuscitated from cardiac arrest; however, the cost effectiveness of multiple TTM methods is not well studied. OBJECTIVE This study aimed to evaluate the cost effectiveness of intravascular temperature management (IVTM) using Thermogard XP compared with surface cooling methods after cardiac arrest in the England from the perspectives of the UK national health service and Personal Social Services. METHODS We developed a multi-state Markov model that evaluated IVTM (Thermogard XP) compared with surface cooling using two different devices (Blanketrol III and Arctic Sun 5000) over a short-term and lifetime time horizon. Model input parameters were obtained from the literature and local databases. We assumed a hypothetical cohort of 1000 patients who required TTM after cardiac arrest per year in the England. The outcomes were costs (in £, year 2019 values) and quality-adjusted life-years (QALYs), discounted at 3.5% annually. Deterministic and probabilistic sensitivity analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results. RESULTS The cost-effectiveness analysis determined that Thermogard XP resulted in direct cost savings of £2339 and £2925 (per patient) compared with Blanketrol III and Arctic Sun 5000, respectively, and a gain of 0.98 QALYs over the patient lifetime. The probabilistic sensitivity analysis demonstrated that the probability of Thermogard XP being cost saving would be 69.2% and 65.3% versus the Arctic Sun 5000 and Blanketrol III, respectively. CONCLUSION Implementation of IVTM using Thermogard XP can lead to cost savings and improved patient quality of life versus surface cooling methods.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, Southampton, UK
| | | | | | | | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon, UK
- MTRC, Anglia Ruskin School of Medicine, Chelmsford, UK
| | - Mohsen Yaghoubi
- Mercer University College of Pharmacy, 3001 Mercer University Dr, Atlanta, GA, 30341, USA.
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Abstract
PURPOSE OF REVIEW Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Best practice has been to cool these patients and control their temperature at a constant value in the range of 32-36 oC for at least 24 h. But the certainty of the evidence for this practice is increasingly being challenged. This review will summarize the evidence on key aspects of temperature control in comatose postcardiac arrest patients. RECENT FINDINGS The Targeted Temperature Management 2 (TTM-2) trial documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC vs. targeted normothermia. A systematic review and meta-analysis completed by the Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) concluded that temperature control with a target of 32-34 °C did not improve survival or favourable functional outcome after cardiac arrest. Two observational studies have documented an association between predicted moderate hypoxic-ischaemic brain injury and better outcome with temperature control at 33-34 oC compared with 35-36 oC. SUMMARY We suggest actively preventing fever by targeting a temperature 37.5 oC or less for those patients who remain comatose following return of spontaneous circulation (ROSC) after cardiac arrest.
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Affiliation(s)
- Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry
- Royal United Hospital, Bath
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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17
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Ramadanov N, Arrich J, Klein R, Herkner H, Behringer W. Intravascular Versus Surface Cooling in Patients Resuscitated From Cardiac Arrest: A Systematic Review and Network Meta-Analysis With Focus on Temperature Feedback. Crit Care Med 2022; 50:999-1009. [PMID: 35089906 PMCID: PMC9112968 DOI: 10.1097/ccm.0000000000005463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to compare the effect of intravascular cooling (IC), surface cooling with temperature feedback (SCF), and surface cooling without temperature feedback (SCnoF) on neurologic outcome and survival in patients successfully resuscitated from cardiac arrest (CA) and treated with targeted temperature management (TTM) at 32-34°C. DATA SOURCES We performed a systematic review on Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, SCOPUS, CINAHL, Web of Science, and Clinical Trials up to June 30, 2021. STUDY SELECTION We included randomized and nonrandomized studies on IC, SCF, and SCnoF in adult humans resuscitated from CA undergoing TTM, reporting neurologic outcome or survival. DATA EXTRACTION We performed a network meta-analysis to assess the comparative effects of IC, SCF, and SCnoF. The overall effect between two cooling methods included the effect of direct and indirect comparisons. Results are given as odds ratios (OR) and 95% CIs. Rankograms estimated the probability of TTM methods being ranked first, second, and third best interventions. DATA SYNTHESIS A total of 14 studies involving 4,062 patients met the inclusion criteria. Four studies were randomized controlled studies, and 10 studies were nonrandomized observational studies. IC compared with SCnoF was significantly associated with better neurologic outcome (OR, 0.6; 95% CI, 0.49-0.74) and survival (OR, 0.8; 95% CI, 0.66-0.96). IC compared with SCF, and SCF compared with SCnoF did not show significant differences in neurologic outcome and survival. The rankogram showed that IC had the highest probability to be the most beneficial cooling method, followed by SCF and SCnoF. CONCLUSIONS Our results suggest that in patients resuscitated from CA and treated with TTM at 32-34°C, IC has the highest probability of being the most beneficial cooling method for survival and neurologic outcome.
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Affiliation(s)
- Nikolai Ramadanov
- Department of Emergency Medicine, Faculty of Medicine, Friedrich Schiller University, Jena, Germany
- Emergency Department, University Hospital Brandenburg, Brandenburg, Germany
| | - Jasmin Arrich
- Department of Emergency Medicine, Faculty of Medicine, Friedrich Schiller University, Jena, Germany
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Klein
- Department for Trauma Surgery and Spine Surgery, ViDia Christian Hospitals, Karlsruhe, Germany
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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18
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Raja S Reddy D, Hanmandlu A. The 4 H's and T's: How reliable is this mnemonic in classifying etiologies of in-hospital cardiac arrests? Resuscitation 2022; 175:3-5. [PMID: 35395339 DOI: 10.1016/j.resuscitation.2022.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Dereddi Raja S Reddy
- Department of Critical Care Medicine, Division of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ankit Hanmandlu
- McGovern Medical School at UTHealth, University of Texas Health Science Center - Houston, Houston, Texas, USA
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19
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Nasir U, Nagalli S, Waheed TA, Zahid S, Qasim M, Sundhu M, Ahuja SK, Ahuja KR. Therapeutic Hypothermia Is Associated With a Decrease in All-cause Mortality in Cardiac Arrest Due to Shockable Rhythm. Crit Pathw Cardiol 2022; 21:47-56. [PMID: 35050948 DOI: 10.1097/hpc.0000000000000277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The benefits of therapeutic hypothermia (TH) in comatose patients postcardiac arrest remain uncertain. While some studies have shown benefit, others have shown equivocal results. We pooled data from randomized controlled trials to better study the outcomes of TH. METHODS Electronic research databases were queried up till September 21, 2021. Randomized controlled trials comparing TH (32-34 °C) with control (normothermia or temperature ≥36 °C) in comatose postcardiac arrest patients were included. RESULTS The study included 10 randomized controlled trials with 3988 subjects (1999 in the TH arm and 1989 in the control arm). There was no difference in all-cause mortality between TH and control (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.66-1.05; P = 0.08; I2 = 41%). There was no difference in the odds of poor neurological outcomes (OR, 0.78; 95% CI, 0.61-1.01; P = 0.07; I2 = 43%). Subgroup analysis showed a decrease in all-cause mortality and poor neurological outcomes with TH in shockable rhythms (OR, 0.55; 95% CI, 0.37-0.80; P = 1.00; I2 = 0% and OR, 0.48; 95% CI, 0.32-0.72; P = 0.92; I2 = 0%, respectively). CONCLUSIONS TH may be beneficial in reducing mortality and poor neurological outcomes in comatose postcardiac arrest patients with shockable rhythms.
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Affiliation(s)
- Usama Nasir
- From the Department of Internal Medicine, Reading Hospital-Tower Health, Reading, PA
| | - Shivaraj Nagalli
- Department of Internal Medicine, Brookwood Baptist Health, Birmingham, AL
| | - Tayyab Ali Waheed
- Department of Cardiovascular Disease, Reading Hospital-Tower Health, Reading, PA
| | - Salman Zahid
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Muhammad Qasim
- Department of Medicine, Indiana University Hospitals, Indianapolis, IN
| | - Murtaza Sundhu
- Department of Cardiovascular Disease, Reading Hospital-Tower Health, Reading, PA
| | - Satish Kumar Ahuja
- Department of Cardiovascular Disease, Reading Hospital-Tower Health, Reading, PA
| | - Keerat Rai Ahuja
- Department of Cardiovascular Disease, Reading Hospital-Tower Health, Reading, PA
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Nolan JP, Sandroni C, Andersen LW, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Lilja G, Morley PT, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone FS, Soar J. ERC-ESICM guidelines on temperature control after cardiac arrest in adults. Resuscitation 2022; 172:229-236. [PMID: 35131119 DOI: 10.1016/j.resuscitation.2022.01.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/11/2022]
Abstract
The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 hours. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Bernd W Böttiger
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Peter T Morley
- University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa M Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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21
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Sandroni C, Nolan JP, Andersen LW, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Lilja G, Morley PT, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone FS, Soar J. ERC-ESICM guidelines on temperature control after cardiac arrest in adults. Intensive Care Med 2022; 48:261-269. [PMID: 35089409 DOI: 10.1007/s00134-022-06620-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/06/2022] [Indexed: 11/05/2022]
Abstract
The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 h. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy. .,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,Department of Intensive Care, Royal United Hospital, Bath, BA1 3NG, UK
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Alain Cariou
- Medical School, Cochin University Hospital (APHP), University of Paris, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium.,Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Peter T Morley
- University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa M Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
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22
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Duan J, Zhai Q, Shi Y, Ge H, Zheng K, Du L, Duan B, Yu J, Ma Q. Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2022; 8:784917. [PMID: 35071355 PMCID: PMC8777010 DOI: 10.3389/fcvm.2021.784917] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20–39 min + TTM, 20–39 min, 40–59 min + TTM, 40–59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20–39 min + TTM group was significantly better than that of the 20–39 min group [odds ratio = 1.41, 95% confidence interval (1.04–1.91); OR = 1.46, 95% CI (1.07–2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61–1.71)/OR = 1.03, 95% CI (0.61–1.75); 40–59 min vs. 40–59 min + TTM: OR = 1.50, 95% CI (0.97–2.32)/OR = 1.40, 95% CI (0.81–2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70–6.24)/OR = 4.14, 95% CI (0.91–18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20–40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027]
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qiangrong Zhai
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Yuanchao Shi
- First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Hongxia Ge
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Lanfang Du
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Baomin Duan
- Emergency Department, Kaifeng Center Hospital, Kaifeng, China
| | - Jie Yu
- The George Institute for Global Health, The University of New South Wales Sydney, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
- Jie Yu
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
- *Correspondence: Qingbian Ma
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23
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Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, Okada N, Kitamura T, Ohta B. Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study. Ann Intensive Care 2021; 11:163. [PMID: 34825993 PMCID: PMC8626556 DOI: 10.1186/s13613-021-00953-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/15/2021] [Indexed: 01/27/2023] Open
Abstract
Background Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm. Methods We retrospectively analysed data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW). Results In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76–3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19–4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83–2.36; OR 1.87, 95% CI 1.01–3.47 among the initial shockable and non-shockable patients, respectively). Conclusion We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00953-y.
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Affiliation(s)
- Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Hikaru Oe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Makoto Sasaki
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Nakamura
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
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24
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Colls Garrido C, Riquelme Gallego B, Sánchez García JC, Cortés Martín J, Montiel Troya M, Rodríguez Blanque R. The Effect of Therapeutic Hypothermia after Cardiac Arrest on the Neurological Outcome and Survival-A Systematic Review of RCTs Published between 2016 and 2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211817. [PMID: 34831572 PMCID: PMC8618610 DOI: 10.3390/ijerph182211817] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 01/10/2023]
Abstract
Therapeutic hypothermia is a treatment used for patients who have suffered cardiorespiratory arrest and remain conscious after the recovery of spontaneous circulation. However, its effectiveness is controversial. The objective of this systematic review is to summarize the scientific evidence available about the effect of therapeutic hypothermia on neurological status and survival in this type of patients. METHODOLOGY A primary search in CINAHL, CUIDEN, Pubmed, Web of Science, and Scopus databases was carried out. Randomized clinical trials (RCT) published from 2016 to 2020 were selected. RESULTS 17 studies were selected for inclusion and most relevant data were extracted. Methodological quality was assessed by the RoB tool. CONCLUSIONS Although therapeutic hypothermia is a safe technique with few adverse and manageable effects, it has not shown to improve survival rate and neurological status of adult nor pediatric patients. It is possible that its positive effect on neuroprotection could be achieved only by preventing hyperthermia although further investigation is needed.
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Affiliation(s)
| | - Blanca Riquelme Gallego
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Instituto de Investigación Biosanitaria, ibs.GRANADA, 18012 Granada, Spain
- Correspondence:
| | - Juan Carlos Sánchez García
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - Jonathan Cortés Martín
- School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain; (J.C.S.G.); (J.C.M.)
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
| | - María Montiel Troya
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- School of Nursing Ceuta Campus, Faculty of Health Sciences, University of Granada, 51001 Ceuta, Spain
| | - Raquel Rodríguez Blanque
- Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, 18014 Granada, Spain; (M.M.T.); (R.R.B.)
- Distrito Sanitario Granada-Metropolitano, 18013 Granada, Spain
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25
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Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW. Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 2021; 167:160-172. [PMID: 34474143 DOI: 10.1016/j.resuscitation.2021.08.040] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/22/2021] [Indexed: 02/04/2023]
Abstract
AIM To perform a systematic review and meta-analysis on targeted temperature management in adult cardiac arrest patients. METHODS PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched on June 17, 2021 for clinical trials. The population included adult patients with cardiac arrest. The review included all aspects of targeted temperature management including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE. RESULTS The systematic search identified 32 trials. Risk of bias was assessed as intermediate for most of the outcomes. For targeted temperature management with a target of 32-34 °C vs. normothermia (which often required active cooling), 9 trials were identified, with six trials included in meta-analyses. Targeted temperature management with a target of 32-34 °C did not result in an improvement in survival (risk ratio: 1.08 [95%CI: 0.89, 1.30]) or favorable neurologic outcome (risk ratio: 1.21 [95%CI: 0.91, 1.61]) at 90 to 180 days after the cardiac arrest (low certainty of evidence). Three trials assessed different hypothermic temperature targets and found no difference in outcomes (low certainty of evidence). Ten trials were identified comparing prehospital cooling vs. no prehospital cooling with no improvement in survival (risk ratio: 1.01 [95%CI: 0.92, 1.11]) or favorable neurologic outcome (risk ratio: 1.00 [95%CI: 0.90, 1.11]) at hospital discharge (moderate certainty of evidence). CONCLUSIONS Among adult patients with cardiac arrest, the use of targeted temperature management at 32-34 °C, when compared to normothermia, did not result in improved outcomes in this meta-analysis. There was no effect of initiating targeted temperature management prior to hospital arrival. These findings warrant an update of international cardiac arrest guidelines.
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Affiliation(s)
- Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Department of Cardiology, Viborg Regional Hospital, Viborg, Denmark
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark.
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26
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Ryu SJ, Lee DH, Lee BK, Jeung KW, Jung YH, Park JS, Min JH, Kim DK. Water Temperature Variability Is Associated with Neurologic Outcomes in Out-of-Hospital Cardiac Arrest Survivors Who Underwent Targeted Temperature Management at 33°C. Ther Hypothermia Temp Manag 2021; 12:74-81. [PMID: 34271840 DOI: 10.1089/ther.2021.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We examined the association between variability in body temperature (BT) and water temperature (WT) during the maintenance period of targeted temperature management (TTM) and neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Adult (≥18 years), comatose OHCA survivors who underwent TTM at 33°C between October 2015 and December 2019 were included. We collected data on BT and WT recorded every minute during the TTM maintenance period. Temperature variability was measured as the standard deviation of BT and WT during the 33°C maintenance period. The primary outcome was a poor neurologic outcome, defined as a cerebral performance category scale 3-5 at 6 months. Of the 154 included patients, 96 (62.3%) had poor outcomes. The BT variability in the poor outcome group was lower than that in the good outcome group (0.16°C [0.13-0.27°C] vs. 0.13°C [0.11-0.18°C]). In addition, the WT variability during the maintenance period in the poor outcome group was lower than that in the good outcome group (2.24°C [1.80-3.96°C] vs. 1.77°C [1.26-2.32°C]). In the multivariate analysis, WT variability (odds ratio 0.508; 95% confidence interval, 0.295-0.874; p = 0.014) was independently associated with poor neurologic outcome. BT variability and cooling beyond 33.0°C ± 1.0°C were not associated with poor neurologic outcomes. WT variability during the maintenance period was independently associated with neurologic outcomes in OHCA survivors who underwent TTM at 33°C. In addition, overcooling or undercooling during the maintenance period was not associated with neurologic outcomes.
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Affiliation(s)
- Seok Jin Ryu
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Dong Ki Kim
- Department of Emergency Medicine, Chonnam National University, Chonnam National University Hospital, Gwangju, Republic of Korea
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27
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Nutma S, le Feber J, Hofmeijer J. Neuroprotective Treatment of Postanoxic Encephalopathy: A Review of Clinical Evidence. Front Neurol 2021; 12:614698. [PMID: 33679581 PMCID: PMC7930064 DOI: 10.3389/fneur.2021.614698] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
Postanoxic encephalopathy is the key determinant of death or disability after successful cardiopulmonary resuscitation. Animal studies have provided proof-of-principle evidence of efficacy of divergent classes of neuroprotective treatments to promote brain recovery. However, apart from targeted temperature management (TTM), neuroprotective treatments are not included in current care of patients with postanoxic encephalopathy after cardiac arrest. We aimed to review the clinical evidence of efficacy of neuroprotective strategies to improve recovery of comatose patients after cardiac arrest and to propose future directions. We performed a systematic search of the literature to identify prospective, comparative clinical trials on interventions to improve neurological outcome of comatose patients after cardiac arrest. We included 53 studies on 21 interventions. None showed unequivocal benefit. TTM at 33 or 36°C and adrenaline (epinephrine) are studied most, followed by xenon, erythropoietin, and calcium antagonists. Lack of efficacy is associated with heterogeneity of patient groups and limited specificity of outcome measures. Ongoing and future trials will benefit from systematic collection of measures of baseline encephalopathy and sufficiently powered predefined subgroup analyses. Outcome measurement should include comprehensive neuropsychological follow-up, to show treatment effects that are not detectable by gross measures of functional recovery. To enhance translation from animal models to patients, studies under experimental conditions should adhere to strict methodological and publication guidelines.
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Affiliation(s)
- Sjoukje Nutma
- Department of Neurology, Medisch Spectrum Twente, Enschede, Netherlands
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Joost le Feber
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Jeannette Hofmeijer
- Clinical Neurophysiology, University of Twente, Enschede, Netherlands
- Department of Neurology, Rijnstate Hospital Arnhem, Arnhem, Netherlands
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28
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Mir T, Sattar Y, Ahmad J, Ullah W, Shanah L, Alraies MC, Qureshi WT. Outcomes of in-hospital cardiac arrest in COVID-19 patients: A proportional prevalence meta-analysis. Catheter Cardiovasc Interv 2021; 99:1-8. [PMID: 33543564 PMCID: PMC8014883 DOI: 10.1002/ccd.29525] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/17/2021] [Indexed: 12/22/2022]
Abstract
Background Limited epidemiological data are available on the outcomes of in‐hospital cardiac arrest (CA) in COVID‐19 patients. Methods We performed literature search of PubMed, EMBASE, Cochrane, and Ovid to identify research articles that studied outcomes of in‐hospital cardiac arrest in COVID‐19 patients. The primary outcome was survival at discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and types of cardiac arrest. Pooled percentages with a 95% confidence interval (CI) were calculated for the prevalence of outcomes. Results A total of 7,891 COVID patients were included in the study. There were 621 (pooled prevalence 8%, 95% CI 4–13%) cardiac arrest patients. There were 52 (pooled prevalence 3.0%; 95% CI 0.0–10.0%) patients that survived at the time of discharge. ROSC was achieved in 202 (pooled prevalence 39%;95% CI 21.0–59.0%) patients. Mean time to ROSC was 7.74 (95% CI 7.51–7.98) min. The commonest rhythm at the time of cardiac arrest was pulseless electrical activity (pooled prevalence 46%; 95% 13–80%), followed by asystole (pooled prevalence 40%; 95% CI 6–80%). Unstable ventricular arrhythmia occurred in a minority of patients (pooled prevalence 8%; 95% CI 4–13%). Conclusion This pooled analysis of studies showed that the survival post in‐hospital cardiac arrest in COVID patients is dismal despite adequate ROSC obtained at the time of resuscitation. Nonshockable rhythm cardiac arrest is commoner suggesting a non‐cardiac cause while cardiac related etiology is uncommon. Future studies are needed to improve the survival in these patients.
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Affiliation(s)
- Tanveer Mir
- Department of Internal Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA
| | - Yasar Sattar
- Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital, Queens, New York, New York, USA
| | - Javeed Ahmad
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Waqas Ullah
- Abington Jefferson Health, Abington, Pennsylvania, USA
| | - Layla Shanah
- Department of Internal Medicine, Wayne State University, Detroit Medical Center, Detroit, Michigan, USA
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical Center, Detroit, Michigan, USA
| | - Waqas T Qureshi
- University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
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Long B, Koyfman A, Gottlieb M. Targeted Temperature Management in Post-Cardiac Arrest Patients. Acad Emerg Med 2020; 27:517-519. [PMID: 31828912 DOI: 10.1111/acem.13904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/05/2019] [Accepted: 12/08/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Brit Long
- From the Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston TX
| | - Alex Koyfman
- the Department of Emergency Medicine The University of Texas Southwestern Medical Center Dallas TX
| | - Michael Gottlieb
- and the Department of Emergency Medicine Rush University Medical Center Chicago IL
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Kim JG, Ahn C, Shin H, Kim W, Lim TH, Jang BH, Cho Y, Choi KS, Lee J, Na MK. Efficacy of the cooling method for targeted temperature management in post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2020; 148:14-24. [DOI: 10.1016/j.resuscitation.2019.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
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Adult post-cardiac arrest interventions: An overview of randomized clinical trials. Resuscitation 2020; 147:1-11. [DOI: 10.1016/j.resuscitation.2019.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/02/2023]
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Liao X, Zhou Z, Zhou M, Tang H, Feng M, Kou B, Zhu N, Liao F, Wu L. Effects of endovascular and surface cooling on resuscitation in patients with cardiac arrest and a comparison of effectiveness, stability, and safety: a systematic review and meta-analysis. Crit Care 2020; 24:27. [PMID: 31992342 PMCID: PMC6988375 DOI: 10.1186/s13054-020-2731-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 01/10/2020] [Indexed: 12/11/2022] Open
Abstract
Objectives This study conducted a meta-analysis to assess the effectiveness, stability, and safety of mild therapeutic hypothermia (TH) induced by endovascular cooling (EC) and surface cooling (SC) and its effect on ICU, survival rate, and neurological function integrity in adult CA patients. Methods We developed inclusion criteria, intervention protocols, results, and data collection. The results included outcomes during target temperature management as well as ICU stay, survival rate, and neurological functional integrity. The characteristics of the included population and each study were analyzed. Results Four thousand nine hundred thirteen participants met the inclusion criteria. Those receiving EC had a better cooling efficiency (cooling rates MD = 0.31[0.13, 0.50], p < 0.01; induced cooling times MD = − 90.45[− 167.57, − 13.33], p = 0.02; patients achieving the target temperature RR = 1.60[1.19, 2.15], p < 0.01) and thermal stability during the maintenance phase (maintenance time MD = 2.35[1.22, 3.48], p < 0.01; temperature fluctuation MD = − 0.68[− 1.03, − 0.33], p < 0.01; overcooling RR = 0.33[0.23, 0.49], p < 0.01). There were no differences in ICU survival rate (RR = 1.22[0.98, 1.52], p = 0.07, I2 = 0%) and hospital survival rate (RR = 1.02 [0.96, 1.09], p = 0.46, I2 = 0%), but EC reduced the length of stay in ICU (MD = − 1.83[− 3.45, − 0.21], p = 0.03, I2 = 49%) and improved outcome of favorable neurological function at discharge (RR = 1.15[1.04, 1.28], p < 0.01, I2 = 0%). EC may delay the hypothermia initiation time, and there was no significant difference between the two cooling methods in the time from the start of patients’ cardiac arrest to achieve the target temperature (MD = − 46.64[− 175.86, 82.58]). EC was superior to non-ArcticSun in terms of cooling efficiency. Although there was no statistical difference in ICU survival rate, ICU length of stay, and hospitalization survival rate, in comparison to non-ArcticSun, EC improved rates of neurologically intact survival (RR = 1.16 [1.01, 1.35], p = 0.04, I2 = 0%). Conclusions Among adult patients receiving cardiopulmonary resuscitation, although there is no significant difference between the two cooling methods in the time from the start of cardiac arrest to achieve the target temperature, the faster cooling rate and more stable cooling process in EC shorten patients’ ICU hospitalization time and help more patients obtain good neurological prognosis compared with patients receiving SC. Meanwhile, although EC has no significant difference in patient outcomes compared with ArcticSun, EC has improved rates of neurologically intact survival.
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Affiliation(s)
- Xueli Liao
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Ziyu Zhou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Manhong Zhou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China.
| | - Hui Tang
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Menglong Feng
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Bujin Kou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Ni Zhu
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Futuan Liao
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Liaozhang Wu
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
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Bartlett ES, Valenzuela T, Idris A, Deye N, Glover G, Gillies MA, Taccone FS, Sunde K, Flint AC, Thiele H, Arrich J, Hemphill C, Holzer M, Skrifvars MB, Pittl U, Polderman KH, Ong MEH, Kim KH, Oh SH, Do Shin S, Kirkegaard H, Nichol G. Systematic review and meta-analysis of intravascular temperature management vs. surface cooling in comatose patients resuscitated from cardiac arrest. Resuscitation 2019; 146:82-95. [PMID: 31730898 DOI: 10.1016/j.resuscitation.2019.10.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To systematically review the effectiveness and safety of intravascular temperature management (IVTM) vs. surface cooling methods (SCM) for induced hypothermia (IH). METHODS Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of included observational studies was graded using the Newcastle-Ottawa Quality Assessment tool. The quality of included randomized trials was evaluated using the Cochrane Collaboration's risk of bias tool. Random effects modeling was used to calculate risk differences for each outcome. Statistical heterogeneity and publication bias were assessed using standard methods. ELIGIBILITY Observational or randomized studies comparing survival and/or neurologic outcomes in adults aged 18 years or greater resuscitated from out-of-hospital cardiac arrest receiving IH via IVTM vs. SCM were eligible for inclusion. RESULTS In total, 12 studies met inclusion criteria. These enrolled 1573 patients who received IVTM; and 4008 who received SCM. Survival was 55.0% in the IVTM group and 51.2% in the SCM group [pooled risk difference 2% (95% CI -1%, 5%)]. Good neurological outcome was achieved in 40.9% in the IVTM and 29.5% in the surface group [pooled risk difference 5% (95% CI 2%, 8%)]. There was a 6% (95% CI 11%, 2%) lower risk of arrhythmia with use of IVTM and 15% (95% CI 22%, 7%) decreased risk of overcooling with use of IVTM vs. SCM. There was no significant difference in other evaluated adverse events between groups. CONCLUSIONS IVTM was associated with improved neurological outcomes vs. SCM among survivors resuscitated following cardiac arrest. These results may have implications for care of patients in the emergency department and intensive care settings after resuscitation from cardiac arrest.
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Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States.
| | - Terence Valenzuela
- Department of Emergency Medicine, University of Arizona, Tucson, AZ, United States; Tucson Fire Department, Tucson, AZ, United States
| | - Ahamed Idris
- Departments of Emergency and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nicolas Deye
- Medical Intensive Care Unit, Inserm U942, Lariboisiere Hospital, APHP, F-75010, Paris, France
| | - Guy Glover
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael A Gillies
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Fabio S Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alexander C Flint
- Divison of Research, Kaiser Permanente, Oakland, CA, United States; Neuroscience Department, Kaiser Permanente, Redwood City, CA, United States
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jasmin Arrich
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria; Center of Emergency Medicine, University of Jena, Faculty of Medicine, Jena, Germany
| | - Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, United States
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Undine Pittl
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Kees H Polderman
- Essex Cardiothoracic Centre, Basildon, Essex, SS16 5NL, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, CM1 1SQ, United Kingdom; United General Hospital, Houston, TX, United States
| | - Marcus E H Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Department of Internal Medicine, University of Washington, Seattle, WA, United States; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States
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Effect of different methods of cooling for targeted temperature management on outcome after cardiac arrest: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:285. [PMID: 31443696 PMCID: PMC6708171 DOI: 10.1186/s13054-019-2567-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/13/2019] [Indexed: 02/03/2023]
Abstract
Background Although targeted temperature management (TTM) is recommended in comatose survivors after cardiac arrest (CA), the optimal method to deliver TTM remains unknown. We performed a meta-analysis to evaluate the effects of different TTM methods on survival and neurological outcome after adult CA. Methods We searched on the MEDLINE/PubMed database until 22 February 2019 for comparative studies that evaluated at least two different TTM methods in CA patients. Data were extracted independently by two authors. We used the Newcastle-Ottawa Scale and a modified Cochrane ROB tools for assessing the risk of bias of each study. The primary outcome was the occurrence of unfavorable neurological outcome (UO); secondary outcomes included overall mortality. Results Our search identified 6886 studies; 22 studies (n = 8027 patients) were included in the final analysis. When compared to surface cooling, core methods showed a lower probability of UO (OR 0.85 [95% CIs 0.75–0.96]; p = 0.008) but not mortality (OR 0.88 [95% CIs 0.62–1.25]; p = 0.21). No significant heterogeneity was observed among studies. However, these effects were observed in the analyses of non-RCTs. A significant lower probability of both UO and mortality were observed when invasive TTM methods were compared to non-invasive TTM methods and when temperature feedback devices (TFD) were compared to non-TFD methods. These results were significant particularly in non-RCTs. Conclusions Although existing literature is mostly based on retrospective or prospective studies, specific TTM methods (i.e., core, invasive, and with TFD) were associated with a lower probability of poor neurological outcome when compared to other methods in adult CA survivors (CRD42019111021). Electronic supplementary material The online version of this article (10.1186/s13054-019-2567-6) contains supplementary material, which is available to authorized users.
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Targeted temperature management after cardiac arrest: Updated meta-analysis of all-cause mortality and neurological outcomes. IJC HEART & VASCULATURE 2019; 24:100400. [PMID: 31384664 PMCID: PMC6661451 DOI: 10.1016/j.ijcha.2019.100400] [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: 01/28/2019] [Revised: 06/28/2019] [Accepted: 07/05/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cardiac arrest carries high mortality and morbidity burden. Different studies showed conflicting data regarding outcomes of targeted temperature management (TTM) for cardiac arrest. The purpose of this meta-analysis is to systematically determine the effect of TTM on all-cause mortality and neurological outcomes after cardiac arrest. METHODS We conducted a systematic search for randomized controlled trials in Pubmed, Cochrane & ScienceDirect. Primary outcomes were neurological outcome and all-cause mortality. RESULTS Nine randomized controlled trials utilizing data for in-hospital and out-of-hospital cardiac arrest were selected for meta-analysis. Total number of patients included was 1592. Mortality was lower in targeted temperature management group (OR 0.637, 95% CI 0.436-0.93, p-value 0.019, I2 = 44.78%, n = 1592). Therapeutic hypothermia group also demonstrated reduction in poor neurological outcomes (OR 0.582, 95% CI 0.363-931, p-value 0.024, I2 = 56.79%, n = 1567). Subgroup analysis was conducted, after excluding in-hospital cardiac arrest patients, and demonstrated reduction in poor neurological outcome (OR 0.562, 95% CI 0.331-0.955, p-value 0.033, I2 = 61.78%, n = 1480) and mortality in out-of-hospital cardiac arrest patients (OR 0.674, 95% CI 0.454-999, p-value 0.049, I2 = 43.8%, n = 1505). CONCLUSION Targeted temperature management after cardiac arrest may be associated with improvement in all-cause mortality and reduction in poor neurological outcome.
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Jun GS, Kim JG, Choi HY, Kang GH, Kim W, Jang YS, Kim HT. A comparison of intravascular and surface cooling devices for targeted temperature management after out-of-hospital cardiac arrest: A nationwide observational study. Medicine (Baltimore) 2019; 98:e16549. [PMID: 31348276 PMCID: PMC6709025 DOI: 10.1097/md.0000000000016549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
This study aimed to compare prognostic difference between intravascular cooling devices (ICDs) and surface cooling devices (SCDs) in targeted temperature management (TTM) recipients.Adult TTM recipients using ICD or SCD during 2012 to 2016 were included in this nationwide observational study. The outcome was survival to hospital discharge and good neurological outcome at hospital discharge.Among 142,905 out-of-hospital cardiac arrest patients, 1159 patients (SCD, n = 998; ICD, n = 161) were investigated. After propensity score matching for all patients, 161 matched pairs of patients were available for analysis (SCD, n = 161; ICD, n = 161). We observed no significant differences in the survival to hospital discharge (SCD, n = 144 [89.4%] vs ICD, n = 150 [93.2%], P = .32) and the good neurological outcomes (SCD, n = 86 [53.4%] vs ICD, n = 91 [56.5%], P = .65). TTM recipients were categorized by age groups (elderly [age >65 years] vs nonelderly [age ≤65 years]) to compare prognostic difference between ICD and SCD according to the age groups. In the nonelderly group, the use of ICD or SCD was not a significant factor for survival to hospital discharge or good neurologic outcome. Whereas, the use of ICD was significantly associated with good neurological outcome (odds ratio, 3.97; 95% confidence interval, 1.19 - 13.23, P = .02) compared with SCD in the elderly group.There were no significant differences in the survival to hospital discharge and the good neurological outcomes between SCD and ICD recipients. However, the use of ICD might be more beneficial than SCD in elderly patients.
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Affiliation(s)
- Gwang Soo Jun
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
| | - Jae Guk Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyun Young Choi
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
| | - Gu Hyun Kang
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
| | - Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
| | - Yong Soo Jang
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
| | - Hyun Tae Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul
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Abstract
IMPORTANCE In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
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Affiliation(s)
- Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Katherine M Berg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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Karcioglu O, Topacoglu H, Dikme O, Dikme O. A systematic review of safety and adverse effects in the practice of therapeutic hypothermia. Am J Emerg Med 2018; 36:1886-1894. [PMID: 30017685 DOI: 10.1016/j.ajem.2018.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/27/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022] Open
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