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Kim YM, Youn CS, Kim SH, Lee BK, Cho IS, Cho GC, Jeung KW, Oh SH, Choi SP, Shin JH, Cha KC, Oh JS, Yim HW, Park KN. Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015. [PMID: 26202789 PMCID: PMC4511983 DOI: 10.1186/s13054-015-0991-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. Methods This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3–5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. Results A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1 %), CPC 4 = 214 (30.4 %), and CPC 5 = 212 (30.1 %)]. Common AEs included hyperglycemia (45.6 %), hypokalemia (31.3 %), arrhythmia (21.3 %) and hypotension (29 %) during cooling, and hypotension (21.6 %) during rewarming. Bleeding (5 %) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6 %), myoclonus (21.9 %), seizures (21.7 %) and hypoglycemia within 72 hours (23 %). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95 % confidence intervals) of 3.12 (1.40–6.97), 3.72 (1.93–7.16), 4.02 (2.04–7.91), 2.03 (1.09–3.78), and 1.69 (1.03–2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28–0.84]). Conclusions Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0991-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Chun Song Youn
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Soo Hyun Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - In Soo Cho
- Department of Emergency Medicine, KEPCO Medical Center, 308 Uicheon-ro, Dobong-gu, Seoul, 132-703, South Korea.
| | - Gyu Chong Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Kangdong Sacread Heart Hospital 150 Seongan-ro, Gangdong-gu, Seoul, 134-701, South Korea.
| | - Kyung Woon Jeung
- Department of Emergency Medicine, College of Medicine, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju, 501-746, South Korea.
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Seung Pill Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Jong Hwan Shin
- Department of Emergency Medicine, Boramae Medical Center, Seoul National University, 20 Boramae-ro, Dongjak-gu, Seoul, 156-707, South Korea.
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, 20 Ilsan-ro, Wonju, Gangwon-do, 220-701, South Korea.
| | - Joo Suk Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, South Korea.
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Hessel EA. Therapeutic hypothermia after in-hospital cardiac arrest: a critique. J Cardiothorac Vasc Anesth 2014; 28:789-99. [PMID: 24751488 DOI: 10.1053/j.jvca.2014.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Indexed: 02/08/2023]
Abstract
More than 210,000 in-hospital cardiac arrests occur annually in the United States. Use of moderate therapeutic hypothermia (TH) in comatose survivors after return of spontaneous circulation following out-of-hospital cardiac arrest (OOH-CA) caused by ventricular fibrillation or pulseless ventricular tachycardia is recommended strongly by many professional organizations and societies. The use of TH after cardiac arrest associated with nonshockable rhythms and after in-hospital cardiac arrest (IH-CA) is recommended to be considered by these same organizations and is being applied widely. The use in these latter circumstances is based on an extrapolation of the data supporting its use after out-of-hospital cardiac arrest associated with shockable rhythms. The purpose of this article is to review the limitations of existing data supporting these extended application of TH after cardiac arrest and to suggest approaches to this dilemma. The data supporting its use for OOH-CA appear to this author, and to some others, to be rather weak, and the data supporting the use of TH for IH-CA appear to be even weaker and to include no randomized controlled trials (RCTs) or supportive observational studies. The many reasons why TH might be expected to be less effective following IH-CA are reviewed. The degree of neurologic injury may be more severe in many of these cases and, thus, may not be responsive to TH as currently practiced following OOH-CA. The potential adverse consequences of the routine use of TH for IH-CA are listed and include complications associated with TH, interference with diagnostic and interventional therapy, and use of scarce personnel and financial resources. Most importantly, it inhibits the ability of researchers to conduct needed RCTs. The author believes that the proper method of providing TH in these cases needs to be better defined. Based on this analysis the author concludes that TH should not be used indiscriminantly following most cases of IH-CA, and instead clinicians should concentrate their efforts in conducting high-quality large RCTs or large-scale, well-designed prospective observation studies to determine its benefits and identify appropriate candidates.
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Affiliation(s)
- Eugene A Hessel
- Department of Anesthesiology, Surgery (Cardiothoracic), Neurosurgery, and Pediatrics, University of Kentucky College of Medicine, Lexington, KY.
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