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Aziz S, Clough M, Butterfield E, Starr Z, Lachowycz K, Price J, Barnard EB, Rees P. The association between prehospital post-return of spontaneous circulation core temperature and survival after out-of-hospital cardiac arrest. Eur J Emerg Med 2024; 31:356-362. [PMID: 38752563 PMCID: PMC11356685 DOI: 10.1097/mej.0000000000001142] [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: 02/20/2024] [Accepted: 04/04/2024] [Indexed: 08/30/2024]
Abstract
BACKGROUND AND IMPORTANCE Following the return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), a low body temperature on arrival at the hospital and on admission to the ICU is reportedly associated with increased mortality. Whether this association exists in the prehospital setting, however, is unknown. OBJECTIVE The objective of this study was to investigate whether the initial, prehospital core temperature measured post-ROSC is independently associated with survival to hospital discharge in adult patients following OHCA. DESIGN, SETTING AND PARTICIPANTS This retrospective observational study was conducted at East Anglian Air Ambulance, a physician-paramedic staffed Helicopter Emergency Medical Service in the East of England, UK. Adult OHCA patients attended by East Anglian Air Ambulance from 1 February 2015 to 30 June 2023, who had post-ROSC oesophageal temperature measurements were included. OUTCOME MEASURE AND ANALYSIS The primary outcome measure was survival to hospital discharge. Core temperature was defined as the first oesophageal temperature recorded following ROSC. Multivariable logistic regression evaluated the adjusted association between core temperature and survival to hospital discharge. MAIN RESULTS Resuscitation was attempted in 3990 OHCA patients during the study period, of which 552 patients were included in the final analysis. The mean age was 61 years, and 402 (72.8%) patients were male. Among them, 194 (35.1%) survived to hospital discharge. The mean core temperature was lower in nonsurvivors compared with those who survived hospital discharge; 34.6 and 35.2 °C, respectively (mean difference, -0.66; 95% CI, -0.87 to -0.44; P < 0.001). The adjusted odds ratio for survival was 1.41 (95% CI, 1.09-1.83; P = 0.01) for every 1.0 °C increase in core temperature between 32.5 and 36.9 °C. CONCLUSION In adult patients with ROSC following OHCA, early prehospital core temperature is independently associated with survival to hospital discharge.
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Affiliation(s)
- Shadman Aziz
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
| | - Molly Clough
- Newcastle University School of Medicine, Newcastle University, Newcastle upon Tyne
| | - Emma Butterfield
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
| | - Zachary Starr
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
| | - Kate Lachowycz
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
| | - James Price
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Ed B.G. Barnard
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham
| | - Paul Rees
- Department of Research, Audit, Innovation and Development, East Anglian Air Ambulance, Norwich
- Barts Interventional Group, Barts Heart Centre, St Bartholomew’s Hospital, London, UK
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Keller S, Kohne S, Bloch W, Schumann M. Comparison of two different cooling systems in alleviating thermal and physiological strain during prolonged exercise in the heat. ERGONOMICS 2021; 64:129-138. [PMID: 32893741 DOI: 10.1080/00140139.2020.1818835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/27/2020] [Indexed: 06/11/2023]
Abstract
This study compared the efficacy of an ice vest comprising of water (WATER) or a water-carbon (CARBON) emulsion on thermophysiological responses to strenuous exercise in the heat. Twelve male cyclists completed three 50-minute constant workload trials (55% of peak power output, ambient temperature 30.4 ± 0.6°C) with WATER, CARBON, and without ice vest (CONTROL), respectively. The increase in core body temperature (Tcore) was lower in WATER at 40 (-0.49 ± 0.34 °C) and 50 minutes (-0.48 ± 0.48 °C) and in CARBON at 30 (-0.41 ± 0.48 °C), 40 (-0.54 ± 0.51 °C), and 50 minutes (-0.67 ± 0.62 °C) as compared to CONTROL (p < 0.05, ES > 0.8). While heart rate and blood lactate kinetics did not differ between the conditions, statistical main effects in favour of both WATER and CARBON were found for thermal sensation (condition p < 0.001 and interaction p < 0.01) and rating of perceived exertion (condition p < 0.05). Per-cooling with CARBON and WATER similarly reduced Tcore but not physiological strain during prolonged exercise in the heat. Practitioner Summary: Exercise in the heat is characterised by increases in thermophysiological strain. Both per-cooling with a novel carbon-based and a conventional water-based ice vest were shown to reduce core temperature significantly. However, due to its lower mass, the carbon-based system may be recommended especially for weight-bearing sports.
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Affiliation(s)
- Sebastian Keller
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Simon Kohne
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Moritz Schumann
- Department of Molecular and Cellular Sports Medicine, Institute of Cardiovascular Research and Sports Medicine, German Sport University Cologne, Cologne, Germany
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Griffiths SA, Ahmad J, Francoeur CL, Gordon E, Dangayach NS, Wheelwright D, Ramineni A, Mayer SA. The EMCOOLs surface cooling system for fever control in neurocritical care patients: A pilot study. Clin Neurol Neurosurg 2019; 184:105412. [PMID: 31323544 DOI: 10.1016/j.clineuro.2019.105412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/13/2019] [Accepted: 07/01/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Fever occurs in up to 50% of critically-ill patients with acute neurological injury. Small temperature elevations have been correlated with increased morbidity and mortality in this patient population. We sought to evaluate a novel single-use surface cooling system for the treatment of fever in patients with acute brain injury. PATIENTS AND METHODS We conducted a retrospective analysis of a prospective product evaluation using the EMCOOLS Flex.Pad™ system for acute fever (≥38.3 °C) in our 16-bed neuro-ICU. Four refrigerated pads (-18 °C) were applied to the chest, back, and anterior thighs. Core temperature (bladder) was continuously recorded over 4 h, and the highest Bedside Shivering Assessment Scale (BSAS) score was recorded hourly. RESULTS Twelve subjects were included in the analysis. Mean age was 55 ± 9 years, 9 patients were men, and mean weight was 85 ± 12 kg. The most common primary diagnoses were subarachnoid (N = 5) and intracerebral (N = 4) hemorrhage. Application of the EMCOOLS system resulted in a linear 1.3 ± 0.6 °C drop (T0avg = 38.9 ⁰C, T90avg = 37.6 ⁰C, P = 0.0032) in mean temperature over 90 min, followed by a plateau with only one subject rebounding to >38 °C within 4 h. Normothermia (<38.0 ⁰C) was achieved in all but one patient (92%) in an average of 65 min. Comatose patients displayed a non-significantly higher degree of cooling at 90 min than did awake subjects (ΔTcoma = 1.74 °C vs ΔTawake = 0.74 °C hr-1, P = 0.067). There was no observed skin irritation upon removal of the device for any patients. CONCLUSION The EMCOOLs system is a well-tolerated, safe and effective short-term intervention for control of fever in neurological patients. Future studies are needed to compare efficacy of the EMCOOLs to other devices and interventions.
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Affiliation(s)
- Stephen A Griffiths
- Mount Sinai Hospital Neuro-ICU, Neurocritical Care Division, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Javaad Ahmad
- Mount Sinai Hospital Neuro-ICU, Neurocritical Care Division, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Charles L Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine) and Department of Critical Care, CHU de Québec-Université Laval, Québec, Canada.
| | - Errol Gordon
- Mount Sinai Hospital Neuro-ICU, Neurocritical Care Division, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Departments of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States; St. John Ascension Health System, Tulsa, OK, United States.
| | - Neha S Dangayach
- Mount Sinai Hospital Neuro-ICU, Neurocritical Care Division, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Departments of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Danielle Wheelwright
- Departments of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Anil Ramineni
- Mount Sinai Hospital Neuro-ICU, Neurocritical Care Division, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Wayne State School of Medicine, Detroit, MI, United States.
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Figueroa SA, Blissitt PA, Livesay S, Wavra T, Guanci MM. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2017; 7:231-234. [PMID: 29058528 DOI: 10.1089/ther.2017.29037.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephen A Figueroa
- 2 Division of Neurocritical Care, The University of Texas Southwestern Medical Center , Dallas, Texas
| | - Patricia A Blissitt
- 3 Harborview Medical Center and Swedish Medical Center, Clinical Faculty, University of Washington School of Nursing , Seattle, Washington
| | - Sarah Livesay
- 4 College of Nursing, Rush University , Chicago, Illinois
| | - Teresa Wavra
- 5 Cardiovascular CNS, Mission Hospital , Mission Viejo, California
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tommasi E, Lazzeri C, Bernardo P, Sori A, Chiostri M, Gensini GF, Valente S. Cooling techniques in mild hypothermia after cardiac arrest. J Cardiovasc Med (Hagerstown) 2017; 18:459-466. [DOI: 10.2459/jcm.0000000000000130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tan PMS, Teo EYN, Ali NB, Ang BCH, Iskandar I, Law LYL, Lee JKW. Evaluation of Various Cooling Systems After Exercise-Induced Hyperthermia. J Athl Train 2017; 52:108-116. [PMID: 28156130 DOI: 10.4085/1062-6050-52.1.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Rapid diagnosis and expeditious cooling of individuals with exertional heat stroke is paramount for survival. OBJECTIVE To evaluate the efficacy of various cooling systems after exercise-induced hyperthermia. DESIGN Crossover study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS Twenty-two men (age = 24 ± 2 years, height = 1.76 ± 0.07 m, mass = 70.7 ± 9.5 kg) participated. INTERVENTION(S) Each participant completed a treadmill walk until body core temperature reached 39.50°C. The treadmill walk was performed at 5.3 km/h on an 8.5% incline for 50 minutes and then at 5.0 km/h until the end of exercise. Each participant experienced 4 cooling phases in a randomized, repeated-crossover design: (1) no cooling (CON), (2) body-cooling unit (BCU), (3) EMCOOLS Flex.Pad (EC), and (4) ThermoSuit (TS). Cooling continued for 30 minutes or until body core temperature reached 38.00°C, whichever occurred earlier. MAIN OUTCOME MEASURE(S) Body core temperature (obtained via an ingestible telemetric temperature sensor) and heart rate were measured continuously during the exercise and cooling phases. Rating of perceived exertion was monitored every 5 minutes during the exercise phase and thermal sensation every minute during the cooling phase. RESULTS The absolute cooling rate was greatest with TS (0.16°C/min ± 0.06°C/min) followed by EC (0.12°C/min ± 0.04°C/min), BCU (0.09°C/min ± 0.06°C/min), and CON (0.06°C/min ± 0.02°C/min; P < .001). The TS offered a greater cooling rate than all other cooling modalities in this study, whereas EC offered a greater cooling rate than both CON and BCU (P < .0083 for all). Effect-size calculations, however, showed that EC and BCU were not clinically different. CONCLUSION These findings provide objective evidence for selecting the most effective cooling system of those we evaluated for cooling individuals with exercise-induced hyperthermia. Nevertheless, factors other than cooling efficacy need to be considered when selecting an appropriate cooling system.
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Affiliation(s)
- Pearl M S Tan
- Combat Protection and Performance, Defence Medical and Environmental Research Institute, Singapore
| | - Eunice Y N Teo
- Combat Protection and Performance, Defence Medical and Environmental Research Institute, Singapore
| | | | - Bryan C H Ang
- Soldier Performance Centre, Singapore Armed Forces.,National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | | | - Lydia Y L Law
- Combat Protection and Performance, Defence Medical and Environmental Research Institute, Singapore
| | - Jason K W Lee
- Combat Protection and Performance, Defence Medical and Environmental Research Institute, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Schock RB, Janata A, Peacock WF, Deal NS, Kalra S, Sterz F. Time to Cooling Is Associated with Resuscitation Outcomes. Ther Hypothermia Temp Manag 2016; 6:208-217. [PMID: 27906641 PMCID: PMC5144870 DOI: 10.1089/ther.2016.0026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Our purpose was to analyze evidence related to timing of cooling from studies of targeted temperature management (TTM) after return of spontaneous circulation (ROSC) after cardiac arrest and to recommend directions for future therapy optimization. We conducted a preliminary review of studies of both animals and patients treated with post-ROSC TTM and hypothesized that a more rapid cooling strategy in the absence of volume-adding cold infusions would provide improved outcomes in comparison with slower cooling. We defined rapid cooling as the achievement of 34°C within 3.5 hours of ROSC without the use of volume-adding cold infusions, with a ≥3.0°C/hour rate of cooling. Using the PubMed database and a previously published systematic review, we identified clinical studies published from 2002 through 2014 related to TTM. Analysis included studies with time from collapse to ROSC of 20–30 minutes, reporting of time from ROSC to target temperature and rate of patients in ventricular tachycardia or ventricular fibrillation, and hypothermia maintained for 20–24 hours. The use of cardiopulmonary bypass as a cooling method was an exclusion criterion for this analysis. We compared all rapid cooling studies with all slower cooling studies of ≥100 patients. Eleven studies were initially identified for analysis, comprising 4091 patients. Two additional studies totaling 609 patients were added based on availability of unpublished data, bringing the total to 13 studies of 4700 patients. Outcomes for patients, dichotomized into faster and slower cooling approaches, were determined using weighted linear regression using IBM SPSS Statistics software. Rapid cooling without volume-adding cold infusions yielded a higher rate of good neurological recovery than slower cooling methods. Attainment of a temperature below 34°C within 3.5 hours of ROSC and using a cooling rate of more than 3°C/hour appear to be beneficial.
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Affiliation(s)
- Robert B Schock
- 1 Sid Wolvek Research Center , Life Recovery Systems HD, LLC, Kinnelon, New Jersey
| | - Andreas Janata
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
| | - W Frank Peacock
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | - Nathan S Deal
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | | | - Fritz Sterz
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 745] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Grave MS, Sterz F, Nürnberger A, Fykatas S, Gatterbauer M, Stättermayer AF, Zajicek A, Malzer R, Sebald D, van Tulder R. Safety and feasibility of the RhinoChill immediate transnasal evaporative cooling device during out-of-hospital cardiopulmonary resuscitation: A single-center, observational study. Medicine (Baltimore) 2016; 95:e4692. [PMID: 27559978 PMCID: PMC5400345 DOI: 10.1097/md.0000000000004692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We investigated feasibility and safety of the RhinoChill (RC) transnasal cooling system initiated before achieving a protected airway during cardiopulmonary resuscitation (CPR) in a prehospital setting.In out-of-hospital cardiac arrest (OHCA), transnasal evaporative cooling was initiated during CPR, before a protected airway was established and continued until either the patient was declared dead, standard institutional systemic cooling methods were implemented or cooling supply was empty. Patients were monitored throughout the hypothermia period until either death or hospital discharge. Clinical assessments and relevant adverse events (AEs) were documented over this period of time.In total 21 patients were included. Four were excluded due to user errors or meeting exclusion criteria. Finally, 17 patients (f = 6; mean age 65.5 years, CI95%: 57.7-73.4) were analyzed. Device-related AEs, like epistaxis or nose whitening, occurred in 2 patients. They were mild and had no consequence on the patient's outcome. According to the field reports of the emergency medical services (EMS) personnel, no severe technical problems occurred by using the RC device that led to a delay or the impairment of quality of the CPR.Early application of the RC device, during OHCA is feasible, safe, easy to handle, and does not delay or hinder CPR, or establishment of a secure intubation. For efficacy and further safety data additional studies will be needed.
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Affiliation(s)
- Marie-Sophie Grave
- Department of Emergency Medicine, Medical University of Vienna
- University Hospital St. Pölten, Karl-Landsteiner Medical University, Lower Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna
- Correspondence: Fritz Sterz, Univ Kl f Notfallmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20/6D, 1090 Wien, Austria (e-mail: )
| | | | | | | | - Albert Friedrich Stättermayer
- Department of Internal Medicine III, Divison of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Dieter Sebald
- Wiener Berufsrettung, Municipal Ambulance Service, Vienna
| | - Raphael van Tulder
- Department of Emergency Medicine, Medical University of Vienna
- Wiener Berufsrettung, Municipal Ambulance Service, Vienna
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Stratil P, Holzer M. Is hypothermia indicated during cardiopulmonary resuscitation and after restoration of spontaneous circulation? Curr Opin Crit Care 2016; 22:212-7. [DOI: 10.1097/mcc.0000000000000299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fukuda T. Targeted temperature management for adult out-of-hospital cardiac arrest: current concepts and clinical applications. J Intensive Care 2016; 4:30. [PMID: 27123306 PMCID: PMC4847228 DOI: 10.1186/s40560-016-0139-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 02/04/2016] [Indexed: 11/25/2022] Open
Abstract
Targeted temperature management (TTM) (primarily therapeutic hypothermia (TH)) after out-of-hospital cardiac arrest (OHCA) has been considered effective, especially for adult-witnessed OHCA with a shockable initial rhythm, based on pathophysiology and on several clinical studies (especially two randomized controlled trials (RCTs) published in 2002). However, a recently published large RCT comparing TTM at 33 °C (TH) and TTM at 36 °C (normothermia) showed no advantage of 33 °C over 36 °C. Thus, this RCT has complicated the decision to perform TH after cardiac arrest. The results of this RCT are sometimes interpreted fever control alone is sufficient to improve outcomes after cardiac arrest because fever control was not strictly performed in the control groups of the previous two RCTs that showed an advantage for TH. Although this may be possible, another interpretation that the optimal target temperature for TH is much lower than 33 °C may be also possible. Additionally, there are many points other than target temperature that are unknown, such as the optimal timing to initiate TTM, the period between OHCA and initiating TTM, the period between OHCA and achieving the target temperature, the duration of maintaining the target temperature, the TTM technique, the rewarming method, and the management protocol after rewarming. RCTs are currently underway to shed light on several of these underexplored issues. In the present review, we examine how best to perform TTM after cardiac arrest based on the available evidence.
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Affiliation(s)
- Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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Zhang XW, Xie JF, Chen JX, Huang YZ, Guo FM, Yang Y, Qiu HB. The effect of mild induced hypothermia on outcomes of patients after cardiac arrest: a systematic review and meta-analysis of randomised controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:417. [PMID: 26619835 PMCID: PMC4665688 DOI: 10.1186/s13054-015-1133-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/06/2015] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Mild induced hypothermia (MIH) is believed to reduce mortality and neurological impairment after out-of-hospital cardiac arrest. However, a recently published trial demonstrated that hypothermia at 33 °C did not confer a benefit compared with that of 36 °C. Thus, a systematic review and meta-analysis of randomised controlled trials (RCTs) was made to investigate the impact of MIH compared to controls on the outcomes of adult patients after cardiac arrest. METHODS We searched the following electronic databases: PubMed/MEDLINE, the Cochrane Library, Embase, the Web of Science, and Elsevier Science (inception to December 2014). RCTs that compared MIH with controls with temperature >34 °C in adult patients after cardiac arrest were retrieved. Two investigators independently selected RCTs and completed an assessment of the quality of the studies. Data were analysed by the methods recommended by the Cochrane Collaboration. Random errors were evaluated with trial sequential analysis. RESULTS Six RCTs, including one abstract, were included. The meta-analysis of included trials revealed that MIH did not significantly decrease the mortality at hospital discharge (risk ratio (RR) = 0.92; 95 % confidence interval (CI), 0.82-1.04; p = 0.17) or at 6 months or 180 days (RR = 0.94; 95 % CI, 0.73-1.21; p = 0.64), but it did reduce the mortality of patients with shockable rhythms at hospital discharge (RR = 0.74; 95 % CI, 0.59-0.92; p = 0.008) and at 6 months or 180 days. However, MIH can improve the outcome of neurological function at hospital discharge (RR = 0.80; 95 % CI, 0.64-0.98; p = 0.04) especially in those patients with shockable rhythm but not at 6 months or 180 days. Moreover, the incidence of complications in the MIH group was significantly higher than that in the control group. Finally, trial sequential analysis indicated lack of firm evidence for a beneficial effect. CONCLUSION The available RCTs suggest that MIH does not appear to improve the mortality of patients with cardiac arrest while it may have a beneficial effect for patients with shockable rhythms. Although MIH may result in some adverse events, it helped lead to better outcomes regarding neurological function at hospital discharge. Large-scale ongoing trials may provide data better applicable to clinical practice.
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Affiliation(s)
- Xi Wen Zhang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Jian Feng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Jian Xiao Chen
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Ying Zi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Feng Mei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
| | - Hai Bo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine Southeast University, No.87, Dingjiaqiao Road, Gulou District, Nanjing, 210009, China.
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Schmid B, Fritz H, Fink K, Eichwede F, Storm C, Elste T, Rössler M, Koberne F, Busch HJ. Präklinische transnasale Kühlung während der Reanimation in Deutschland. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0043-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Howes D, Gray SH, Brooks SC, Boyd JG, Djogovic D, Golan E, Green RS, Jacka MJ, Sinuff T, Chaplin T, Smith OM, Owen J, Szulewski A, Murphy L, Irvine S, Jichici D, Muscedere J. Canadian Guidelines for the use of targeted temperature management (therapeutic hypothermia) after cardiac arrest: A joint statement from The Canadian Critical Care Society (CCCS), Canadian Neurocritical Care Society (CNCCS), and the Canadian Critical Care Trials Group (CCCTG). Resuscitation 2015; 98:48-63. [PMID: 26417702 DOI: 10.1016/j.resuscitation.2015.07.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 07/25/2015] [Accepted: 07/30/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel Howes
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada; Queen's University, Kingston, ON, Canada.
| | - Sara H Gray
- Division of Emergency Medicine, Department of Medicine, and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Steven C Brooks
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada; Rescu, Li Ka Shing Knowledge Institute, St. Michael's, Toronto, ON, Canada
| | - J Gordon Boyd
- Queen's University, Kingston, ON, Canada; Division of Neurology Department of Medicine Queen's University, Kingston, ON, Canada
| | - Dennis Djogovic
- Division of Critical Care Medicine and Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Eyal Golan
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Robert S Green
- Department of Emergency Medicine, Department of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada
| | - Michael J Jacka
- Departments of Anesthesiology and Critical Care, University of Alberta Hospital, Edmonton, AB, Canada
| | - Tasnim Sinuff
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Timothy Chaplin
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada
| | - Orla M Smith
- Critical Care Department, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, ON, Canada
| | - Julian Owen
- McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Adam Szulewski
- Department of Emergency Medicine Queen's University, Kingston, ON, Canada
| | - Laurel Murphy
- Department of Emergency Medicine, Department of Critical Care Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Draga Jichici
- Department of Neurology and Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - John Muscedere
- Queen's University, Kingston, ON, Canada; Department of Medicine Queen's University, Kingston, ON, Canada
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Jinka TR, Combs VM, Drew KL. Translating drug-induced hibernation to therapeutic hypothermia. ACS Chem Neurosci 2015; 6:899-904. [PMID: 25812681 DOI: 10.1021/acschemneuro.5b00056] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Therapeutic hypothermia (TH) improves prognosis after cardiac arrest; however, thermoregulatory responses such as shivering complicate cooling. Hibernators exhibit a profound and safe reversible hypothermia without any cardiovascular side effects by lowering the shivering threshold at low ambient temperatures (Ta). Activation of adenosine A1 receptors (A1ARs) in the central nervous system (CNS) induces hibernation in hibernating species and a hibernation-like state in rats, principally by attenuating thermogenesis. Thus, we tested the hypothesis that targeted activation of the central A1AR combined with a lower Ta would provide a means of managing core body temperature (Tb) below 37 °C for therapeutic purposes. We targeted the A1AR within the CNS by combining systemic delivery of the A1AR agonist (6)N-cyclohexyladenosine (CHA) with 8-(p-sulfophenyl)theophylline (8-SPT), a nonspecific adenosine receptor antagonist that does not readily cross the blood-brain barrier. Results show that CHA (1 mg/kg) and 8-SPT (25 mg/kg), administered intraperitoneally every 4 h for 20 h at a Ta of 16 °C, induce and maintain the Tb between 29 and 31 °C for 24 h in both naïve rats and rats subjected to asphyxial cardiac arrest for 8 min. Faster and more stable hypothermia was achieved by continuous infusion of CHA delivered subcutaneously via minipumps. Animals subjected to cardiac arrest and cooled by CHA survived better and showed less neuronal cell death than normothermic control animals. Central A1AR activation in combination with a thermal gradient shows promise as a novel and effective pharmacological adjunct for inducing safe and reversible targeted temperature management.
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Affiliation(s)
- Tulasi R. Jinka
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
- University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Velva M. Combs
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
| | - Kelly L. Drew
- University of Alaska Fairbanks, 902 North Koyukuk Drive, Fairbanks, Alaska 99775-7000, United States
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Feketa VV, Marrelli SP. Induction of therapeutic hypothermia by pharmacological modulation of temperature-sensitive TRP channels: theoretical framework and practical considerations. Temperature (Austin) 2015; 2:244-57. [PMID: 27227027 PMCID: PMC4844121 DOI: 10.1080/23328940.2015.1024383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022] Open
Abstract
Therapeutic hypothermia has emerged as a remarkably effective method of neuroprotection from ischemia and is being increasingly used in clinics. Accordingly, it is also a subject of considerable attention from a basic scientific research perspective. One of the fundamental problems, with which current studies are concerned, is the optimal method of inducing hypothermia. This review seeks to provide a broad theoretical framework for approaching this problem, and to discuss how a novel promising strategy of pharmacological modulation of the thermosensitive ion channels fits into this framework. Various physical, anatomical, physiological and molecular aspects of thermoregulation, which provide the foundation for this text, have been comprehensively reviewed and will not be discussed exhaustively here. Instead, the first part of the current review, which may be helpful for a broader readership outside of thermoregulation research, will build on this existing knowledge to outline possible opportunities and research directions aimed at controlling body temperature. The second part, aimed at a more specialist audience, will highlight the conceptual advantages and practical limitations of novel molecular agents targeting thermosensitive Transient Receptor Potential (TRP) channels in achieving this goal. Two particularly promising members of this channel family, namely TRP melastatin 8 (TRPM8) and TRP vanilloid 1 (TRPV1), will be discussed in greater detail.
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Key Words
- DMH, dorso-medial hypothalamus
- MPA, medial preoptic area of hypothalamus
- TRP, Transient Receptor Potential
- TRPA1, Transient Receptor Potential cation channel, subfamily A, member 1
- TRPM8, Transient Receptor Potential cation channel, subfamily M, member 8
- TRPV1, Transient Receptor Potential cation channel, subfamily V, member 1
- TRPV2, Transient Receptor Potential cation channel, subfamily V, member 2
- TRPV3, Transient Receptor Potential cation channel, subfamily V, member 3
- TRPV4, Transient Receptor Potential cation channel, subfamily V, member 4
- ThermoTRPs
- ThermoTRPs, Thermosensitive Transient Receptor Potential cation channels
- body temperature
- core temperature
- pharmacological hypothermia
- physical cooling
- rMR, rostral medullary raphe region
- therapeutic hypothermia
- thermopharmacology
- thermoregulation
- thermosensitive ion channels
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Affiliation(s)
- Viktor V Feketa
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine , Houston, TX, USA
| | - Sean P Marrelli
- Department of Molecular Physiology and Biophysics Graduate Program; Cardiovascular Sciences Track; Baylor College of Medicine, Houston, TX, USA; Department of Anesthesiology; Baylor College of Medicine, Houston, TX, USA
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Uray T, Mayr FB, Stratil P, Aschauer S, Testori C, Sterz F, Haugk M. Prehospital surface cooling is safe and can reduce time to target temperature after cardiac arrest. Resuscitation 2014; 87:51-6. [PMID: 25447355 DOI: 10.1016/j.resuscitation.2014.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/25/2014] [Accepted: 10/30/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Mild therapeutic hypothermia proved to be beneficial when induced after cardiac arrest in humans. Prehospital cooling with i.v. fluids was associated with adverse side effects. Our primary objective was to compare time to target temperature of out-of hospital cardiac arrest patients cooled non-invasively either in the prehospital setting vs. the in-hospital (IH) setting, to assess surface-cooling safety profile and long term outcome. METHODS In this retrospective, single center cohort study, a group of adult patients with restoration of spontaneous circulation (ROSC) after out-of hospital cardiac arrest were cooled with a surface cooling pad beginning either in the prehospital or IH setting for 24h. Time to target temperature (33.9°C), temperature on admission, time to admission after ROSC and outcome were compared. Also, rearrests and pulmonary edema were assessed. Neurologic outcome at 12 months was evaluated (Cerebral Performance Category, CPC 1-2, favorable outcome). RESULTS Between September 2005 and February 2010, 56 prehospital cooled patients and 54 IH-cooled patients were treated. Target temperature was reached in 85 (66-117)min (prehospital) and in 135 (102-192)min (IH) after ROSC (p<0.001). After prehospital cooling, hospital admission temperature was 35.2 (34.2-35.8)°C, and in the IH-cooling patients initial temperature was 35.8 (35.2-36.3)°C (p=0.001). No difference in numbers of rearrests and pulmonary edema between groups was observed. In both groups, no skin lesions were observed. Favorable outcome was reached in 26.8% (prehospital) and in 37.0% (IH) of the patients (p=0.17). CONCLUSIONS Using a non-invasive prehospital surface cooling method after cardiac arrest, target temperature can be reached faster without any major complications than starting cooling IH. The effect of early non-invasive cooling on long-term outcome remains to be determined in larger studies.
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Affiliation(s)
- Thomas Uray
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Florian B Mayr
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, PA, USA
| | - Peter Stratil
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Stefan Aschauer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christoph Testori
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Austria.
| | - Moritz Haugk
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Uray T, Kochanek PM. Finding a faster and safer way to "catch a cold" after cardiac arrest: we may be getting closer. Resuscitation 2014; 85:1131-3. [PMID: 24992871 DOI: 10.1016/j.resuscitation.2014.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 06/23/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas Uray
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
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Abstracts from the 3rd innsbruck targeted temperature management symposium-a multidisciplinary conference september 21, 2013 vienna, austria. Ther Hypothermia Temp Manag 2014; 3:A1-A14. [PMID: 24834952 DOI: 10.1089/ther.2013.1517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do. Resuscitation 2013; 85:376-80. [PMID: 24300012 DOI: 10.1016/j.resuscitation.2013.11.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 11/04/2013] [Accepted: 11/16/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) is one of three interventions that have demonstrated to improve patients' neurological outcome after cardiac arrest. The aim of this study was to investigate the effect of the 2010 resuscitation guidelines on TH implementation in various Italian Intensive Care Units (ICU). METHODS A structured questionnaire was submitted to Italian ICU. The questionnaire was addressed to determine the procedures of TH in each ICU or, on the contrary, the reason for not employing the therapy. RESULTS We obtained complete information from 770 of 847 Italian ICU (91%). Out of 405 Units included in the analysis only 223 (55.1%) reported to use TH in comatose patients after return of spontaneous circulation. The trend of TH implementation shows a stable increase, particularly after 2006 but there is no evident acceleration after the strong indication of the 2010 guidelines. There was a rise of about 3.4 times in the number of Italian ICU using TH as compared to the 2007 survey (an increase of 68% per year). One hundred and eighty-two (44.9%) units did not use TH mainly because of lack of equipment, economic issues or the conviction of the difficulty of execution. CONCLUSIONS TH is still under-used in Italy (55.1%) even though the therapy is strongly recommended in the 2010 guidelines. However, the increase in the adoption of hypothermia has been significant in the past 5 years (68%/years) and the awareness of the efficacy is almost consolidated among intensivists, being logistic problems the leading cause for non-adoption.
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Rapid induction of mild therapeutic hypothermia by extracorporeal veno-venous blood cooling in humans. Resuscitation 2013; 84:1051-5. [DOI: 10.1016/j.resuscitation.2013.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 02/20/2013] [Accepted: 03/06/2013] [Indexed: 11/20/2022]
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Tisherman SA. Targeted temperature management after cardiac arrest: how invasive do we need to be? Resuscitation 2013; 84:1009-10. [PMID: 23684806 DOI: 10.1016/j.resuscitation.2013.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 05/09/2013] [Indexed: 11/18/2022]
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Alkadri ME, Peters MN, Katz MJ, White CJ. State-of-the-art paper: Therapeutic hypothermia in out of hospital cardiac arrest survivors. Catheter Cardiovasc Interv 2013; 82:E482-90. [PMID: 23475635 DOI: 10.1002/ccd.24914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 01/12/2013] [Accepted: 03/03/2013] [Indexed: 11/09/2022]
Abstract
Out of hospital cardiac arrest (OHCA) is associated with an extremely poor survival rate, with mortality in most cases being related to neurological injury. Among patients who experience return of spontaneous circulation (ROSC), therapeutic hypothermia (TH) is the only proven intervention shown to reduce mortality and improve neurological outcome. First described in 1958, the field of TH has rapidly evolved in recent years. While recent technological advances in TH will likely improve outcomes in OHCA survivors, several fundamental questions remain to be answered including the optimal speed of cooling, which patients benefit from an early invasive strategy, and whether technological advances will facilitate application of TH in the field. An increased awareness and understanding of TH strategies, devices, monitoring, techniques, and complications will allow for a more widespread adoption of this important treatment modality.
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Affiliation(s)
- Mohi E Alkadri
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
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Zellner T, Gärtner R, Schopohl J, Angstwurm M. NSE and S-100B are not sufficiently predictive of neurologic outcome after therapeutic hypothermia for cardiac arrest. Resuscitation 2013; 84:1382-6. [PMID: 23528678 DOI: 10.1016/j.resuscitation.2013.03.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 02/02/2013] [Accepted: 03/10/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Prognostication of cardiac arrest survivors is challenging since therapeutic hypothermia (TH) has been introduced. We evaluated serum biomarkers and motor response. METHODS This was a retrospective data analysis including patients in the years 2007-2012. Blood was drawn and a neurological examination was performed on admission and every morning. Outcomes were evaluated 6 months after discharge and dichotomized into good (cerebral performance category (CPC)=1 or 2) and poor (CPC=3, 4 or 5). RESULTS 123 patients (79.7% male, 63±14 years) received TH; 50% had a good outcome. On admission, S-100B (P=0.004) was significantly associated with the outcome, as well as neuron-specific enolase (NSE; P=0.020) and S-100B (P=0.004) on day 1 after admission. NSE on day 2, NSE progression from day 1 to 2 and motor response on day 3 also predicted the outcome (all P<0.001). NSE>33μgl(-1) only predicted a poor outcome with a specificity of 76%. An absent motor response on day 3 was the most sensitive marker (94%). NSE>41.1μgl(-1) combined with S-100B>0.461μgl(-1) on day 1 was the most specific marker (96%). CONCLUSION Although NSE and S-100B levels are associated with the outcome, the use of previously described cut-off values was insufficiently predictive of neurologic outcome. Caution should be exercised in the use of these tests to provide neuroprognostication.
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Affiliation(s)
- T Zellner
- Intensive Care Unit, Medizinische Klinik Innenstadt (Ludwig-Maximilians-Universität), Munich, Germany.
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Diao M, Huang F, Guan J, Zhang Z, Xiao Y, Shan Y, Lin Z, Ding L. Prehospital therapeutic hypothermia after cardiac arrest: a systematic review and meta-analysis of randomized controlled trials. Resuscitation 2013; 84:1021-8. [PMID: 23454259 DOI: 10.1016/j.resuscitation.2013.02.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 02/02/2013] [Accepted: 02/03/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Therapeutic hypothermia has been recommended for the treatment of cardiac arrest patients who remain comatose after the return of spontaneous circulation. However, the optimal time to initiate therapeutic hypothermia remains unclear. The objective of the present study is to assess the effectiveness and safety of prehospital therapeutic hypothermia after cardiac arrest. METHODS Databases such as MEDLINE, Embase, and Cochrane Library were searched from their establishment date to May of 2012 to retrieve randomized control trials on prehospital therapeutic hypothermia after cardiac arrest. Thereafter, the studies retrieved were screened based on predefined inclusion and exclusion criteria. Data were extracted and the quality of the included studies was evaluated. A meta-analysis was performed by using the Cochrane Collaboration Review Manager 5.1.6 software. RESULTS Five studies involving 633 cases were included, among which 314 cases were assigned to the treatment group and the other 319 cases to the control group. The meta-analysis indicated that prehospital therapeutic hypothermia after cardiac arrest produced significant differences in temperature on hospital admission compared with in-hospital therapeutic hypothermia or normothermia (patient data; mean difference=-0.95; 95% confidence interval -1.15 to -0.75; I(2)=0%). However, no significant differences were observed in the survival to the hospital discharge, favorable neurological outcome at hospital discharge, and rearrest. The risk of bias was low; however, the quality of the evidence was very low. CONCLUSION This review demonstrates that prehospital therapeutic hypothermia after cardiac arrest can decrease temperature on hospital admission. On the other hand, regarding the survival to hospital discharge, favorable neurological outcome at hospital discharge, and rearrest, our meta-analysis and review produces non-significant results. Using the Grading of Recommendations, Assessment, Development and Evaluation methodology, we conclude that the quality of evidence is very low.
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Affiliation(s)
- Mengyuan Diao
- Department of Emergency and Critical Care Medicine, Shanghai Changzheng Hospital, Shanghai, China
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Vaicys V, Eason A, Schieber JD, Kulstad EB. Therapeutic hypothermia induction via an esophageal route—a computer simulation. Am J Emerg Med 2012; 30:932-5. [DOI: 10.1016/j.ajem.2011.04.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 03/27/2011] [Accepted: 04/18/2011] [Indexed: 10/18/2022] Open
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Abstract
Therapeutic hypothermia (TH) is the intentional reduction of core body temperature to 32°C to 35°C, and is increasingly applied by intensivists for a variety of acute neurological injuries to achieve neuroprotection and reduction of elevated intracranial pressure. TH improves outcomes in comatose patients after a cardiac arrest with a shockable rhythm, but other off-label applications exist and are likely to increase in the future. This comprehensive review summarizes the physiology and cellular mechanism of action of TH, as well as different means of TH induction and maintenance with potential side effects. Indications of TH are critically reviewed by disease entity, as reported in the most recent literature, and evidence-based recommendations are provided.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Jiaying Zhang
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
- Departments of Neurology (Division of Neurocritical Care), Anesthesia/Critical Care and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
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Weng Y, Sun S. Therapeutic hypothermia after cardiac arrest in adults: mechanism of neuroprotection, phases of hypothermia, and methods of cooling. Crit Care Clin 2011; 28:231-43. [PMID: 22433485 DOI: 10.1016/j.ccc.2011.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Yinlun Weng
- The Weil Institute of Critical Care Medicine, Rancho Mirage, CA 92270, USA
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Testori C, Sterz F, Behringer W, Spiel A, Firbas C, Jilma B. Surface cooling for induction of mild hypothermia in conscious healthy volunteers - a feasibility trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R248. [PMID: 22018242 PMCID: PMC3334799 DOI: 10.1186/cc10506] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/28/2011] [Accepted: 10/22/2011] [Indexed: 01/07/2023]
Abstract
Introduction Animal and human studies suggest beneficial outcome effects of mild hypothermia for stroke, for acute myocardial infarction, and for cardiogenic shock. The aim of this study was to investigate the feasibility and safety of non-invasive surface cooling for induction and maintenance of mild hypothermia (32 to 34°C) in healthy, conscious volunteers. Methods The trial was set at a clinical research ward in a tertiary care center, and included 16 healthy male volunteers 18 to 70 years old. Surface cooling was established by a novel non-invasive cooling pad with an esophageal target temperature of 32 to 34°C and maintenance for six hours. Shivering-control was achieved with meperidine and buspirone and additional administration of magnesium in eight subjects. Results The primary endpoint to reach a target temperature of 32 to 34°C was only reached in 6 of the 16 participating subjects. Temperatures below 35°C were reached after a median cooling time of 53 minutes (38 to 102 minutes). Cooling rate was 1.1°C/h (0.7 to 1.8°C). Additional administration of magnesium had no influence on cooling rate. At no time during the cooling procedure did the participants report uncomfortable conditions for which termination of cooling had to be considered. No severe skin damage was reported. Conclusions Cooling to body temperature below 35°C by the use of non-invasive surface cooling is feasible and safe in conscious healthy volunteers. Further studies are needed to investigate an altered cooling protocol to achieve temperatures below 35°C. Trial Registration ISRCTN: ISRCTN50530495
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Affiliation(s)
- Christoph Testori
- Department of Emergency Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Leary M, Vanek F, Abella BS. Prehospital Use of Therapeutic Hypothermia After Resuscitation from Cardiac Arrest. Ther Hypothermia Temp Manag 2011; 1:69-75. [DOI: 10.1089/ther.2011.0001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marion Leary
- Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Florence Vanek
- Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Benjamin S. Abella
- Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2011; 81:1305-52. [PMID: 20956049 DOI: 10.1016/j.resuscitation.2010.08.017] [Citation(s) in RCA: 751] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Comparison of surface cooling and invasive cooling for rapid induction of mild therapeutic hypothermia in pigs--effectiveness of two different devices. Resuscitation 2011; 81:1704-8. [PMID: 20926173 DOI: 10.1016/j.resuscitation.2010.08.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 08/13/2010] [Accepted: 08/25/2010] [Indexed: 11/21/2022]
Abstract
AIM OF THE STUDY The effectiveness and safety of non-invasive surface cooling was compared to invasive endovascular cooling in an animal model. METHODS Eight healthy pigs (29-38 kg) were cooled twice, starting in the first 4 pigs with unique surface cooling pads followed by endovascular cooling. In the second 4 pigs the order was reversed. The goal was to quickly lower pulmonary artery temperature from 38 to 33°C. A paired t-test was used to compare cooling rates (°C/h, mean±standard deviation) between both cooling techniques. RESULTS Mean non-invasive surface cooling rate (11.9±3.8°C/h) significantly exceeded mean invasive cooling rate (3.9±0.7°C/h; p<0.001). The mean difference in cooling rates was 8.0±3.6°C/h. No surface cooling related adverse skin reactions were observed. CONCLUSIONS Surface cooling is a simple method for achieving fast cooling rates. In our animal model, non-invasive cooling was three times faster than rapid endovascular cooling without overshoot.
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Cabanas JG, Brice JH, De Maio VJ, Myers B, Hinchey PR. Field-induced Therapeutic Hypothermia for Neuroprotection after Out-of Hospital Cardiac Arrest: A Systematic Review of the Literature. J Emerg Med 2011; 40:400-9. [DOI: 10.1016/j.jemermed.2010.07.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Revised: 05/07/2010] [Accepted: 07/06/2010] [Indexed: 11/30/2022]
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Inamasu J, Nakatsukasa M, Suzuki M, Miyatake S. Therapeutic hypothermia for out-of-hospital cardiac arrest: an update for neurosurgeons. World Neurosurg 2011; 74:120-8. [PMID: 21300001 DOI: 10.1016/j.wneu.2010.02.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 02/20/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Neurosurgeons have been familiar with the idea that hypothermia is protective against various types of brain injuries, including traumatic brain injury (TBI). Recent randomized controlled trials, however, have failed to demonstrate the efficacy of therapeutic hypothermia (TH) in patients with TBI. On the other hand, TH becomes popular in the treatment of out-of-hospital cardiac arrest (OHCA) survivors, after randomized controlled trials have shown that survival rate and functional outcome is improved with the use of TH in selected patients. We believe that knowledge on the recent progress in TH for OHCA is useful for neurosurgeons, because feedback of information obtained in the treatment of OHCA may revitalize the interest in TH for neurosurgical disorders, particularly TBI. METHODS A review of the literature was conducted with the use of PubMed. RESULTS Various cooling techniques and devices have been developed and trialed in the treatment of OHCA survivors, including prehospital cooling with bolus ice-cold saline, endovascular cooling catheters, and new generation surface cooling devices, some of which have already been known to neurosurgeons. The efficacy of these new methods and devices has been demonstrated in many preliminary studies, and phase III trials are also expected. CONCLUSIONS Neurosurgeons and critical care medicine physicians pursue the same goal of rescuing the brain from the secondary injury despite the difference in etiology (focal trauma vs. global ischemia), with the presumption that earlier and faster implementation of TH will result in better outcome. Thoughtful application of knowledge and techniques obtained in OHCA to TBI under a rigorously controlled situation will make a small, but significant difference in the outcome of TBI victims.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan.
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Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e93-e174. [PMID: 20956032 DOI: 10.1016/j.resuscitation.2010.08.027] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Walters JH, Morley PT, Nolan JP. The role of hypothermia in post-cardiac arrest patients with return of spontaneous circulation: a systematic review. Resuscitation 2011; 82:508-16. [PMID: 21367510 DOI: 10.1016/j.resuscitation.2011.01.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 01/23/2011] [Accepted: 01/26/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To update a comprehensive systematic review of the use of therapeutic hypothermia after cardiac arrest that was undertaken initially as part of the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. The specific question addressed was: 'in post-cardiac arrest patients with a return of spontaneous circulation, does the induction of mild hypothermia improve morbidity or mortality when compared with usual care?' METHODS Pubmed was searched using ("heart arrest" or "cardiopulmonary resuscitation") AND "hypothermia, induced" using 'Clinical Queries' search strategy; EmBASE was searched using (heart arrest) OR (cardiopulmonary resuscitation) AND hypothermia; The Cochrane database of systematic reviews; ECC EndNote Library for "hypothermia" in abstract OR title. Excluded were animal studies, reviews and editorials, surveys of implementation, analytical models, reports of single cases, pre-arrest or during arrest cooling and group where the intervention was not hypothermia alone. RESULTS 77 studies met the criteria for further review. Of these, four were meta-analyses (LOE 1); seven were randomised controlled trials (LOE 1), although six of these were from the same set of patients; nine were non-randomised, concurrent controls (LOE 2); 15 were trials with retrospective controls (LOE 3); 40 had no controls (LOE 4); and one was extrapolated from a non-cardiac arrest group (LOE 5). CONCLUSION There is evidence supporting the use of mild therapeutic hypothermia to improve neurological outcome in patients who remain comatose following the return of spontaneous circulation after a cardiac arrest; however, much of the evidence is from low-level, observational studies. Of seven randomised controlled trials, six use data from the same patients.
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Affiliation(s)
- James H Walters
- Intensive Care Medicine, Royal United Hospital, Bath BA1 3NG, UK.
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Weihs W, Schratter A, Sterz F, Janata A, Högler S, Holzer M, Losert UM, Herkner H, Behringer W. The importance of surface area for the cooling efficacy of mild therapeutic hypothermia. Resuscitation 2011; 82:74-8. [PMID: 21036458 DOI: 10.1016/j.resuscitation.2010.09.472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 08/31/2010] [Accepted: 09/25/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Wolfgang Weihs
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Skulec R, Truhlár A, Seblová J, Dostál P, Cerný V. Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline. Crit Care 2010; 14:R231. [PMID: 21176218 PMCID: PMC3219975 DOI: 10.1186/cc9386] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 08/20/2010] [Accepted: 12/22/2010] [Indexed: 11/17/2022] Open
Abstract
Introduction Pre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service. The safety and impact on the clinical outcome have also been analyzed. Methods We performed a prospective observational study with a retrospective control group. A total of 40 patients were cooled by an intravenous administration of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital (TH group). The pre-hospital decrease of tympanic temperature (TT) was analyzed as the primary endpoint. Patients in the control group did not undergo any pre-hospital cooling. Results In the TH group, administration of 12.6 ± 6.4 ml/kg of 4°C cold normal saline was followed by a pre-hospital decrease of TT of 1.4 ± 0.8°C in 42.8 ± 19.6 min (p < 0.001). The most effective cooling was associated with a transport time duration of 38-60 min and with an infusion of 17 ml/kg of cold saline. In the TH group, a trend toward a reduced need for catecholamines during transport was detected (35.0 vs. 52.5%, p = 0.115). There were no differences in demographic variables, comorbidities, parameters of the cardiopulmonary resuscitation and in other post-resuscitation characteristics. The coupling of pre-hospital cooling with subsequent in-hospital TH predicted a favorable neurological outcome at hospital discharge (OR 4.1, CI95% 1.1-18.2, p = 0.046). Conclusions Pre-hospital induction of TH by the rapid intravenous administration of cold normal saline has been shown to be efficient even with a lower dose of coolant than reported in previous studies. This dose can be associated with a favorable impact on circulatory stability early after the return of spontaneous circulation and, when coupled with in-hospital continuation of cooling, can potentially improve the prognosis of patients. Trial Registration ClinicalTrials (NCT): NCT00915421
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Affiliation(s)
- Roman Skulec
- Emergency Medical Service of the Central Bohemian Region, Prof, Veseleho 461, Beroun 266 01, Czech Republic.
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Mild therapeutic hypothermia in pre-hospital care: 8 for versus 8 against? COR ET VASA 2010. [DOI: 10.33678/cor.2010.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, Lavonas EJ, Link MS, Neumar RW, Otto CW, Parr M, Shuster M, Sunde K, Peberdy MA, Tang W, Hoek TLV, Böttiger BW, Drajer S, Lim SH, Nolan JP, Adrie C, Alhelail M, Battu P, Behringer W, Berkow L, Bernstein RA, Bhayani SS, Bigham B, Boyd J, Brenner B, Bruder E, Brugger H, Cash IL, Castrén M, Cocchi M, Comadira G, Crewdson K, Czekajlo MS, Davies SR, Dhindsa H, Diercks D, Dine CJ, Dioszeghy C, Donnino M, Dunning J, El Sanadi N, Farley H, Fenici P, Feeser VR, Foster JA, Friberg H, Fries M, Garcia-Vega FJ, Geocadin RG, Georgiou M, Ghuman J, Givens M, Graham C, Greer DM, Halperin HR, Hanson A, Holzer M, Hunt EA, Ishikawa M, Ioannides M, Jeejeebhoy FM, Jennings PA, Kano H, Kern KB, Kette F, Kudenchuk PJ, Kupas D, La Torre G, Larabee TM, Leary M, Litell J, Little CM, Lobel D, Mader TJ, McCarthy JJ, McCrory MC, Menegazzi JJ, Meurer WJ, Middleton PM, Mottram AR, Navarese EP, Nguyen T, Ong M, Padkin A, Ferreira de Paiva E, Passman RS, Pellis T, Picard JJ, Prout R, Pytte M, Reid RD, Rittenberger J, Ross W, Rubertsson S, Rundgren M, Russo SG, Sakamoto T, Sandroni C, Sanna T, Sato T, Sattur S, Scapigliati A, Schilling R, Seppelt I, Severyn FA, Shepherd G, Shih RD, Skrifvars M, Soar J, Tada K, Tararan S, Torbey M, Weinstock J, Wenzel V, Wiese CH, Wu D, Zelop CM, Zideman D, Zimmerman JL. Part 8: Advanced Life Support. Circulation 2010; 122:S345-421. [DOI: 10.1161/circulationaha.110.971051] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this study is to discuss recent data relating to the treatment of cardiac arrest survivors. This is a rapidly evolving component of resuscitation medicine that impacts significantly on the quality of survival after cardiac arrest. RECENT FINDINGS The postcardiac arrest syndrome comprises postcardiac arrest brain injury, postcardiac arrest myocardial dysfunction, the systemic ischaemia/reperfusion response, and the persistent precipitating disease. Primary percutaneous coronary intervention is the preferred method for restoring coronary perfusion when cardiac arrest has been caused by an ST-elevation myocardial infarction. Many cardiac arrest survivors with non-ST-elevation myocardial infarction may also benefit from urgent percutaneous coronary intervention. Comatose cardiac arrest survivors should be managed with a moderate blood glucose target range of below 10 mmol/l (180 mg/dl). Therapeutic hypothermia is now generally accepted as part of a treatment strategy for comatose survivors of cardiac arrest, but its use may render conventional methods of prognostication unreliable. SUMMARY Survivors from cardiac arrest develop a postcardiac arrest syndrome. Postresuscitation care, including primary percutaneous coronary intervention, therapeutic hypothermia, and control of blood sugar, improves survival and neurological outcome in cardiac arrest survivors. Completely reliable prognostication in comatose survivors of cardiac arrest is difficult to achieve.
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Haugk M, Stratil P, Sterz F, Krizanac D, Testori C, Uray T, Koller J, Behringer W, Holzer M, Herkner H. Temperature monitored on the cuff surface of an endotracheal tube reflects body temperature. Crit Care Med 2010; 38:1569-73. [PMID: 20495450 DOI: 10.1097/ccm.0b013e3181e47a20] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE When treating patients with cardiac arrest with mild therapeutic hypothermia, a reliable and easy-to-use temperature probe is desirable. This study was conducted to investigate the accuracy and safety of tracheal temperature as a measurement of body temperature. DESIGN Observational cohort study. SETTING Emergency department of a tertiary care university hospital. PATIENTS Patients successfully resuscitated from cardiac arrest intended for mild hypothermia therapy. INTERVENTIONS Intubation was performed with a newly developed endotracheal tube that contains a temperature sensor inside the cuff surface. During the cooling, mild hypothermia maintenance, and rewarming phases, the temperature was recorded minute by minute. These data were compared with the temperature assessed by esophageal and blood temperature probes. Thereafter, tracheoscopy was performed to evaluate the condition of the tracheal mucosa. MEASUREMENTS AND MAIN RESULTS Approximately 2000 measurements per temperature sensor per patient were recorded in 21 patients. The mean bias between the blood temperature and the tracheal temperature was -0.16 degrees C (limits of agreement: -0.36 degrees C to 0.04 degrees C). The mean bias between the esophageal and tracheal temperatures was -0.22 degrees C (limits of agreement: -0.49 degrees C to 0.07 degrees C). Agreement between temperature probes investigated by the Bland-Altman method showed a mean bias of less than -(1/4) degrees C, and time lags assessed graphically by hysteresis plots were negligible. No clinically relevant injury to the tracheal mucosa was detected. CONCLUSION Temperature monitoring at the cuff surface of an endotracheal tube is safe and provides accurate and reliable data in all phases of therapeutically induced mild hypothermia after cardiac arrest.
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Affiliation(s)
- Moritz Haugk
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Su Z, Li C, Han Y, Yin X, Guo M. Evaluation of cerebral metabolism by ¹H-magnetic resonance spectroscopy for 4°C saline-induced therapeutic hypothermia in pig model of cardiac arrest. Am J Emerg Med 2010; 29:913-21. [PMID: 20627218 DOI: 10.1016/j.ajem.2010.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 03/06/2010] [Accepted: 04/14/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Previous studies have shown that therapeutic hypothermia could improve neurologic recovery when induced after cardiac arrest, but dynamic changes in cerebral metabolism have not been studied at low temperature. In this study, we aim to evaluate hypothermia-induced changes in pigs' cerebral metabolism by (1)H-magnetic resonance spectroscopy (¹H-MRS). MATERIAL AND METHODS Ten anesthetized Landrace (25-30 kg) pigs were randomized into 2 groups and subjected to 4 minutes of ventricular fibrillation, followed by cardiopulmonary resuscitation. The hypothermic group was given an infusion of 30 mL/kg of 4°C normal saline (NS) at an infusion rate of 1.33 mL/kg per minute starting after restoration of spontaneous circulation (ROSC), then 10 mL/kg per hour for 4 hours. The control group received the same infusion of room temperature NS. Core temperature and hemodynamic variables were monitored at baseline and repeatedly for 240 minutes after ROSC. The ¹H-MRS scans were obtained at baseline, 1 hour, and 3 hours after successful ROSC to observe the dynamic changes of cerebral metabolism at different temperatures. RESULTS The mean reduction of temperature was 1.5°C ± 0.4°C in the hypothermic group. There was no difference in hemodynamic variables between groups. ¹H-MRS detected statistically significant (P < .01) changes in cerebral metabolism between the control and hypothermia groups (P < .01). CONCLUSIONS Infusion of 4°C NS can effectively reduce cerebral metabolism after successful cardiopulmonary resuscitation and have a protective effect on the recovery of neurologic function. The ¹H-MRS technology can be used as a powerful tool to evaluate interventions in the treatment of cardiopulmonary resuscitation.
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Affiliation(s)
- Zhiyu Su
- Emergency Department, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China.
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Boller M, Lampe JW, Katz JM, Barbut D, Becker LB. Feasibility of intra-arrest hypothermia induction: A novel nasopharyngeal approach achieves preferential brain cooling. Resuscitation 2010; 81:1025-30. [PMID: 20538402 DOI: 10.1016/j.resuscitation.2010.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Revised: 03/16/2010] [Accepted: 04/05/2010] [Indexed: 01/21/2023]
Abstract
AIM In patients with cardiopulmonary arrest, brain cooling may improve neurological outcome, especially if applied prior to or during early reperfusion. Thus it is important to develop feasible cooling methods for pre-hospital use. This study examines cerebral and compartmental thermokinetic properties of nasopharyngeal cooling during various blood flow states. METHODS Ten swine (40+/-4kg) were anesthetized, intubated and monitored. Temperature was determined in the frontal lobe of the brain, in the aorta, and in the rectum. After the preparatory phase the cooling device (RhinoChill system), which produces evaporative cooling in the nasopharyngeal area, was activated for 60min. The thermokinetic response was evaluated during stable anaesthesia (NF, n=3); during untreated cardiopulmonary arrest (ZF, n=3); during CPR (LF, n=4). RESULTS Effective brain cooling was achieved in all groups with a median cerebral temperature decrease of -4.7 degrees C for NF, -4.3 degrees C for ZF and -3.4 degrees C for LF after 60min. The initial brain cooling rate however was fastest in NF, followed by LF, and was slowest in ZF; the median brain temperature decrease from baseline after 15min of cooling was -2.48 degrees C for NF, -0.12 degrees C for ZF, and -0.93 degrees C for LF, respectively. A median aortic temperature change of -2.76 degrees C for NF, -0.97 for LF and +1.1 degrees C for ZF after 60min indicated preferential brain cooling in all groups. CONCLUSION While nasopharyngeal cooling in swine is effective at producing preferential cerebral hypothermia in various blood flow states, initial brain cooling is most efficient with normal circulation.
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Affiliation(s)
- Manuel Boller
- Center for Resuscitation Science, Department of Emergency Medicine, School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, United States.
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Tulder R, Vorauer N, Schreiber W. Therapiestrategien des Post-Reanimationssyndromes. Notf Rett Med 2010. [DOI: 10.1007/s10049-009-1278-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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