1
|
Lee HY, Tien YT, Huang CH, Chen WJ, Chen WT, Chang WT, Ong HN, Tsai MS. The compliance with TTM protocol may benefit outcomes in cardiac arrest survivors: A retrospective cohort study. Am J Emerg Med 2024; 84:87-92. [PMID: 39106738 DOI: 10.1016/j.ajem.2024.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/27/2024] [Accepted: 07/24/2024] [Indexed: 08/09/2024] Open
Abstract
BACKGROUND Established protocols for implementing high-quality targeted temperature management (TTM) provide guidance concerning the cooling rate, duration of maintenance, and rewarming speed. However, whether compliant to TTM protocols results in improved survival and better neurological recovery has not been examined. METHODS A retrospective cohort study enrolled 1141 survivors of non-traumatic adult cardiac arrest with a pre-arrest cerebral performance category (CPC) score of 1-2 from 2015 to 2020 at a tertiary medical center. Of the survivors, 330 patients who underwent TTM were further included. Patients with spontaneous hypothermia (<35 °C) (n = 107) and expired during the TTM (n = 21) were excluded. A total of 202 patients were thus enrolled. One hundred and ten patients underwent TTM that completely complied with the protocol (protocol-complaint group), but 92 patients deviated in some manner from the protocol (protocol non-compliant group). RESULTS Fifty patients (50%) and 46 patients (50%) in the protocol-compliant and non-compliant groups, respectively, did not survive to hospital discharge. In the protocol-compliant group, 42 patients (38.2%) had favorable neurological recovery, compared with 32 patients (34.8%) in the protocol non-compliant group. After adjusting for age, initial shockable rhythm, witnessed collapse, and cardiopulmonary resuscitation duration, protocol non-compliant was associated with the poor neurological outcomes (aOR 2.44, 95% CI = 1.13-5.25), but not with in-hospital mortality (aOR 1.31, 95% CI = 0.70-2.47). The most common reason for noncompliance was a prolonged duration reaching the target temperature (n = 33, 58.7%). The number of phases of non-compliant was not significantly associated with in-hospital mortality or poor neurological recovery. CONCLUSION Among cardiac arrest survivors undergoing TTM, those who did not receive TTM that in compliance with the protocol were more likely to experience poor neurological recovery than those whose TTM fully complied with the protocols. The most frequently identified deviation was a prolonged duration to reaching the target temperature.
Collapse
Affiliation(s)
- Hsin-Yu Lee
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Yu-Tzu Tien
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan; Department of Internal Medicine (Cardiology division), National Taiwan University Medical College and Hospital, Taipei, Taiwan; Department of Internal Medicine (Cardiology Division), Min-Sheng General Hospital, Taoyuan, Taiwan
| | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Hooi-Nee Ong
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
| |
Collapse
|
2
|
Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024; 44:308-323. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
Collapse
Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
3
|
Kadden M, Zhang A, Shoykhet M. Association of temperature management strategy with fever in critically ill children after out-of-hospital cardiac arrest. Front Pediatr 2024; 12:1355385. [PMID: 38659696 PMCID: PMC11039828 DOI: 10.3389/fped.2024.1355385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Objective To determine whether ICU temperature management strategy is associated with fever in children with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). Methods We conducted a single-center retrospective cohort study at a quaternary Children's hospital between 1/1/2016-31/12/2020. Mechanically ventilated children (<18 y/o) admitted to Pediatric or Cardiac ICU (PICU/CICU) with ROSC after OHCA who survived at least 72 h were included. Primary exposure was initial PICU/CICU temperature management strategy of: (1) passive management; or (2) warming with an air-warming blanket; or (3) targeted temperature management with a heating/cooling (homeothermic) blanket. Primary outcome was fever (≥38°C) within 72 h of admission. Results Over the study period, 111 children with ROSC after OHCA were admitted to PICU/CICU, received mechanical ventilation and survived at least 72 h. Median age was 31 (IQR 6-135) months, 64% (71/111) were male, and 49% (54/111) were previously healthy. Fever within 72 h of admission occurred in 51% (57/111) of patients. The choice of initial temperature management strategy was associated with occurrence of fever (χ2 = 9.36, df = 2, p = 0.009). Fever occurred in 60% (43/72) of patients managed passively, 45% (13/29) of patients managed with the air-warming blanket and 10% (1/10) of patients managed with the homeothermic blanket. Compared to passive management, use of homeothermic, but not of air-warming, blanket reduced fever risk [homeothermic: Risk Ratio (RR) = 0.17, 95%CI 0.03-0.69; air-warming: RR = 0.75, 95%CI 0.46-1.12]. To prevent fever in one child using a homeothermic blanket, number needed to treat (NNT) = 2. Conclusion In critically ill children with ROSC after OHCA, ICU temperature management strategy is associated with fever. Use of a heating/cooling blanket with homeothermic feedback reduces fever incidence during post-arrest care.
Collapse
Affiliation(s)
- Micah Kadden
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Pediatric Critical Care Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States
| | - Anqing Zhang
- Division of Biostatistics and Study Methodology, Children’s National Hospital, Silver Spring, MD, United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
| | - Michael Shoykhet
- Pediatric Critical Care Medicine, Children’s National Hospital, Washington, DC,United States
- Department of Pediatrics, School of Medicine and Health Sciences, The George Washington University, Washington, DC,United States
| |
Collapse
|
4
|
Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
Collapse
Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
| |
Collapse
|
5
|
Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW. Temperature control after adult cardiac arrest: An updated systematic review and meta-analysis. Resuscitation 2023; 191:109928. [PMID: 37558083 DOI: 10.1016/j.resuscitation.2023.109928] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
AIM To perform an updated systematic review and meta-analysis on temperature control in adult patients with cardiac arrest. METHODS The review is an update of a previous systematic review published in 2021. An updated search including PubMed, Embase, and the Cochrane Central Register of Controlled Trials was performed on May 31, 2023. Controlled trials in humans were included. The population included adult patients with cardiac arrest. The review included all aspects of temperature control including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE. RESULTS The updated systematic search identified six new trials. Risk of bias in the trials was assessed as intermediate for most of the outcomes. For temperature control with a target of 32-34 °C vs. normothermia or 36 °C, two new trials were identified, with seven trials included in an updated meta-analysis. Temperature control with a target of 32-34 °C did not result in an improvement in survival (risk ratio: 1.06 [95%CI: 0.91, 1.23]) or favorable neurological outcome (risk ratio: 1.27 [95%CI: 0.89, 1.81]) at 90-180 days after the cardiac arrest (low certainty evidence). Subgroup analysis according to location of cardiac arrest (in-hospital vs. out-of-hospital) found similar results. A sensitivity analysis of nine trials comparing temperature control at 32-34 °C to normothermia or 36 °C for favorable neurological outcome at any time point also did not show an improvement in outcomes (risk ratio: 1.14 [95%CI 0.98, 1.34]). New individual trials comparing a target of 31-34 °C, temperature control for 12-24 hours to 36 hours, a rewarming rate of 0.25-0.5 °C/hour, and the effect of temperature control with fever prevention found no differences in outcomes. CONCLUSIONS This updated systematic review showed no benefit of temperature control at 32-34 °C compared to normothermia or 36 °C, although the 95% confidence intervals cannot rule out a potential beneficial effect. Important knowledge gaps exist for topics such as hypothermic temperature targets, rewarming rate, and fever control.
Collapse
Affiliation(s)
- Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Mathias J Holmberg
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark; Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| |
Collapse
|
6
|
Chalkias A, Adamos G, Mentzelopoulos SD. General Critical Care, Temperature Control, and End-of-Life Decision Making in Patients Resuscitated from Cardiac Arrest. J Clin Med 2023; 12:4118. [PMID: 37373812 DOI: 10.3390/jcm12124118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Cardiac arrest affects millions of people per year worldwide. Although advances in cardiopulmonary resuscitation and intensive care have improved outcomes over time, neurologic impairment and multiple organ dysfunction continue to be associated with a high mortality rate. The pathophysiologic mechanisms underlying the post-resuscitation disease are complex, and a coordinated, evidence-based approach to post-resuscitation care has significant potential to improve survival. Critical care management of patients resuscitated from cardiac arrest focuses on the identification and treatment of the underlying cause(s), hemodynamic and respiratory support, organ protection, and active temperature control. This review provides a state-of-the-art appraisal of critical care management of the post-cardiac arrest patient.
Collapse
Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, University of Thessaly, 41500 Larisa, Greece
- Outcomes Research Consortium, Cleveland, OH 44195, USA
| | - Georgios Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, 10675 Athens, Greece
| |
Collapse
|
7
|
Hassager C, Schmidt H, Møller JE, Grand J, Mølstrøm S, Beske RP, Boesgaard S, Borregaard B, Bekker-Jensen D, Dahl JS, Frydland MS, Høfsten DE, Isse YA, Josiassen J, Lind Jørgensen VR, Kondziella D, Lindholm MG, Moser E, Nyholm BC, Obling LER, Sarkisian L, Søndergaard FT, Thomsen JH, Thune JJ, Venø S, Wiberg SC, Winther-Jensen M, Meyer MAS, Kjaergaard J. Duration of Device-Based Fever Prevention after Cardiac Arrest. N Engl J Med 2023; 388:888-897. [PMID: 36342119 DOI: 10.1056/nejmoa2212528] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Guidelines recommend active fever prevention for 72 hours after cardiac arrest. Data from randomized clinical trials of this intervention have been lacking. METHODS We randomly assigned comatose patients who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause to device-based temperature control targeting 36°C for 24 hours followed by targeting of 37°C for either 12 or 48 hours (for total intervention times of 36 and 72 hours, respectively) or until the patient regained consciousness. The primary outcome was a composite of death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 (range, 1 to 5, with higher scores indicating more severe disability; a category of 3 or 4 indicates severe cerebral disability or coma) within 90 days after randomization. Secondary outcomes included death from any cause and the Montreal Cognitive Assessment score (range, 0 to 30, with higher scores indicating better cognitive ability) at 3 months. RESULTS A total of 393 patients were randomly assigned to temperature control for 36 hours, and 396 patients were assigned to temperature control for 72 hours. At 90 days after randomization, a primary end-point event had occurred in 127 of 393 patients (32.3%) in the 36-hour group and in 133 of 396 patients (33.6%) in the 72-hour group (hazard ratio, 0.99; 95% confidence interval, 0.77 to 1.26; P = 0.70) and mortality was 29.5% in the 36-hour group and 30.3% in the 72-hour group. At 3 months, the median Montreal Cognitive Assessment score was 26 (interquartile range, 24 to 29) and 27 (interquartile range, 24 to 28), respectively. There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS Active device-based fever prevention for 36 or 72 hours after cardiac arrest did not result in significantly different percentages of patients dying or having severe disability or coma. (Funded by the Novo Nordisk Foundation; BOX ClinicalTrials.gov number, NCT03141099.).
Collapse
Affiliation(s)
- Christian Hassager
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Henrik Schmidt
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jacob E Møller
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Johannes Grand
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Simon Mølstrøm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Rasmus P Beske
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Boesgaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Britt Borregaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Ditte Bekker-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jordi S Dahl
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin S Frydland
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Dan E Høfsten
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Yusuf A Isse
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob Josiassen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Vibeke R Lind Jørgensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Daniel Kondziella
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matias G Lindholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Emil Moser
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Benjamin C Nyholm
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laust E R Obling
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Laura Sarkisian
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Frederik T Søndergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jakob H Thomsen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jens J Thune
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Søren Venø
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Sebastian C Wiberg
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Matilde Winther-Jensen
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Martin A S Meyer
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| | - Jesper Kjaergaard
- From the Departments of Cardiology (C.H., J.G., R.P.B., S.B., M.S.F., D.E.H., Y.A.I., J.J., M.G.L., B.C.N., L.E.R.O., F.T.S., J.H.T., S.C.W., M.W.-J., M.A.S.M., J.K.) and Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital, the Departments of Clinical Medicine (C.H., D.K., J.K.) and Cardiothoracic Anesthesiology (V.R.L.J.), University of Copenhagen, and the Department of Cardiology, Copenhagen University Hospital Bispebjerg (J.J.T.), Copenhagen, and the Department of Clinical Research, University of Southern Denmark (C.H., H.S., J.E.M., B.B., J.S.D.), and the Departments of Anesthesiology and Intensive Care (H.S., S.M., E.M., S.V.) and Cardiology (J.E.M., B.B., D.B.-J., J.S.D., L.S.), Odense University Hospital, Odense - all in Denmark
| |
Collapse
|
8
|
Therapeutic Hypothermia Following Cardiac Arrest After the TTM2 trial - More Questions Raised Than Answered. Curr Probl Cardiol 2023; 48:101046. [PMID: 34780867 DOI: 10.1016/j.cpcardiol.2021.101046] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/05/2021] [Indexed: 02/06/2023]
Abstract
For almost 20 years, therapeutic hypothermia has been a cornerstone of modern post-cardiac arrest care lowering mortality, and improvin neurologic outcome compared to conventional therapy. This was challenged by the first TTM-trial in 2013, which did not show a benefit for hypothermia at 33°C compared to controlled normothermia at 36°C. Now, the TTM2 trial showed no benefit of hypothermia compared to fever prevention alone. While TTM1 and TTM2 suggest that hypothermia might not be helpful, a deep dive into the trials reveals that this conclusion does not hold true. Here, we focus on patient selection, suboptimal application of hypothermia, interaction of standard sedation with hypothermia, high incidence of post-arrest fever, and withdrawal of life support based on per-protocol neurologic prognostication in the TTM2-trial. Of particular interest, contemporary trials and registries using intravascular cooling in TTM-like patients repeatedly reported much lower mortality rates than those described in both TTM1 and TTM2.
Collapse
|
9
|
Wang D, Wang L, Sun Y, Kong F, Jiang Y, An M, Xia Y, Gong P, Yang Y. Effects of temperature control on hyperthermia-related cardiac dysfunction in a porcine model of cardiac arrest. Cryobiology 2023; 110:49-55. [PMID: 36509162 DOI: 10.1016/j.cryobiol.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
The outcome of cardiac arrest is worse when there is fever after spontaneous circulation is restored (ROSC). The purpose of this study was to investigate the mechanism of post-ROSC cardiac dysfunction after hyperthermia treatment and the effects of temperature control. Twenty-four male Bama minipigs were randomized into 3 groups (8 per group): CPR + controlled normothermia (CN), CPR + hyperthermia (HT), and CPR + therapeutic mild hypothermia (TMH). Defibrillation was given to pigs with ventricular fibrillation after 8 min of untreated fibrillation. Subsequently, these animals received the post-ROSC treatments of hyperthermia (38 °C), controlled normothermia (37 °C) or hypothermia (33 °C) according to the groups. Hemodynamic parameters, left ventricular ejection fraction, blood samples and myocardial tissues were assessed. At 24 h after the post-ROSC treatments, the pigs treated with hyperthermia showed increments in heart rate and plasma cardiac troponin I, and decreases in mean arterial pressure, cardiac index, and left ventricular ejection fraction, compared to those with the controlled normothermia pigs. However, the deterioration of the above parameters can be attenuated by TMH. The pigs in the TMH group also had a reduced percentage of apoptotic cardiomyocytes, an increased anti-apoptotic Bcl-2/Bax ratio and a decreased caspase-3 activity in myocardium, as compared with both controlled normothermia and hyperthermia pigs. In conclusion, hyperthermia is associated with a worse myocardial dysfunction. TMH improves hyperthermia-induced myocardial dysfunction by attenuating apoptosis in a porcine model of cardiac arrest.
Collapse
Affiliation(s)
- Dongxia Wang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Ling Wang
- Department of Emergency, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Yuanyuan Sun
- Department of Emergency, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Fang Kong
- Department of Emergency, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Yi Jiang
- Department of Emergency, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Mengmeng An
- Department of Emergency, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Yunlong Xia
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Ping Gong
- Department of Emergency, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China.
| | - Yanzong Yang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| |
Collapse
|
10
|
Belur AD, Sedhai YR, Truesdell AG, Khanna AK, Mishkin JD, Belford PM, Zhao DX, Vallabhajosyula S. Targeted Temperature Management in Cardiac Arrest: An Updated Narrative Review. Cardiol Ther 2023; 12:65-84. [PMID: 36527676 PMCID: PMC9986171 DOI: 10.1007/s40119-022-00292-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36 °C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32-34 °C) versus higher (36 °C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.
Collapse
Affiliation(s)
- Agastya D Belur
- Division of Cardiology, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Yub Raj Sedhai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Kentucky College of Medicine, Bowling Green, KY, USA
| | | | - Ashish K Khanna
- Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA.,Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
| | - Joseph D Mishkin
- Section of Advanced Heart Failure and Transplant Cardiology, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, USA
| | - P Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA
| | - Saraschandra Vallabhajosyula
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA. .,Section of Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, 306 Westwood Avenue, Suite 401, High Point, Winston-Salem, NC, 27262, USA. .,Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| |
Collapse
|
11
|
Li P, Sun Z, Tian T, Yu D, Tian H, Gong P. Recent developments and controversies in therapeutic hypothermia after cardiopulmonary resuscitation. Am J Emerg Med 2023; 64:1-7. [PMID: 36435004 DOI: 10.1016/j.ajem.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/23/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022] Open
Abstract
Therapeutic hypothermia was recommended as the only neuroprotective treatment in comatose patients after return of spontaneous circulation (ROSC). With new evidence suggesting a similar neuroprotective effect of 36 °C and 33 °C, the term "therapeutic hypothermia" was substituted by "targeted temperature management" in 2011, which in turn was replaced by the term "temperature control" in 2022 because of new evidence of the similar effects of target normothermia and 33 °C. However, there is no clear consensus on the efficacy of therapeutic hypothermia. In this article, we provide an overview of the recent evidence from basic and clinical research related to therapeutic hypothermia and re-evaluate its application as a post-ROSC neuroprotective intervention in clinical settings.
Collapse
Affiliation(s)
- Peijuan Li
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Zhangping Sun
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Tian Tian
- Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; Dalian Medical University, Dalian, Liaoning, China
| | - Dongping Yu
- Department of Emergency, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hui Tian
- Department of Emergency, Dalian Municipal Central Hospital, Dalian, Liaoning, China
| | - Ping Gong
- Department of Emergency, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China; Department of Emergency, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China.
| |
Collapse
|
12
|
Sandroni C, Natalini D, Nolan JP. Temperature control after cardiac arrest. Crit Care 2022; 26:361. [PMID: 36434649 PMCID: PMC9700892 DOI: 10.1186/s13054-022-04238-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/27/2022] Open
Abstract
Most of the patients who die after cardiac arrest do so because of hypoxic-ischemic brain injury (HIBI). Experimental evidence shows that temperature control targeted at hypothermia mitigates HIBI. In 2002, one randomized trial and one quasi-randomized trial showed that temperature control targeted at 32-34 °C improved neurological outcome and mortality in patients who are comatose after cardiac arrest. However, following the publication of these trials, other studies have questioned the neuroprotective effects of hypothermia. In 2021, the largest study conducted so far on temperature control (the TTM-2 trial) including 1900 adults comatose after resuscitation showed no effect of temperature control targeted at 33 °C compared with normothermia or fever control. A systematic review of 32 trials published between 2001 and 2021 concluded that temperature control with a target of 32-34 °C compared with fever prevention did not result in an improvement in survival (RR 1.08; 95% CI 0.89-1.30) or favorable functional outcome (RR 1.21; 95% CI 0.91-1.61) at 90-180 days after resuscitation. There was substantial heterogeneity across the trials, and the certainty of the evidence was low. Based on these results, the International Liaison Committee on Resuscitation currently recommends monitoring core temperature and actively preventing fever (37.7 °C) for at least 72 h in patients who are comatose after resuscitation from cardiac arrest. Future studies are needed to identify potential patient subgroups who may benefit from temperature control aimed at hypothermia. There are no trials comparing normothermia or fever control with no temperature control after cardiac arrest.
Collapse
Affiliation(s)
- Claudio Sandroni
- grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy ,grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart. Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS. L.go F, Vito 1, 00168 Rome, Italy
| | - Daniele Natalini
- grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy
| | - Jerry P. Nolan
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, CV4 7AL UK ,grid.416091.b0000 0004 0417 0728Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG UK
| |
Collapse
|
13
|
Wolfrum S, Roedl K, Hanebutte A, Pfeifer R, Kurowski V, Riessen R, Daubmann A, Braune S, Söffker G, Bibiza-Freiwald E, Wegscheider K, Schunkert H, Thiele H, Kluge S. Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. Circulation 2022; 146:1357-1366. [PMID: 36168956 DOI: 10.1161/circulationaha.122.060106] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study was conducted to determine the effect of hypothermic temperature control after in-hospital cardiac arrest (IHCA) on mortality and functional outcome as compared with normothermia. METHODS An investigator initiated, open-label, blinded-outcome-assessor, multicenter, randomized controlled trial comparing hypothermic temperature control (32-34°C) for 24 h with normothermia after IHCA in 11 hospitals in Germany. The primary endpoint was all-cause mortality after 180 days. Secondary end points included in-hospital mortality and favorable functional outcome using the Cerebral Performance Category scale after 180 days. A Cerebral Performance Category score of 1 or 2 was defined as a favorable functional outcome. RESULTS A total of 1055 patients were screened for eligibility and 249 patients were randomized: 126 were assigned to hypothermic temperature control and 123 to normothermia. The mean age of the cohort was 72.6±10.4 years, 64% (152 of 236) were male, 73% (166 of 227) of cardiac arrests were witnessed, 25% (57 of 231) had an initial shockable rhythm, and time to return of spontaneous circulation was 16.4±10.5 minutes. Target temperature was reached within 4.2±2.8 hours after randomization in the hypothermic group and temperature was controlled for 48 hours at 37.0°±0.9°C in the normothermia group. Mortality by day 180 was 72.5% (87 of 120) in hypothermic temperature control arm, compared with 71.2% (84 of 118) in the normothermia group (relative risk, 1.03 [95% CI, 0.79-1.40]; P=0.822). In-hospital mortality was 62.5% (75 of 120) in the hypothermic temperature control as compared with 57.6% (68 of 118) in the normothermia group (relative risk, 1.11 [95% CI, 0.86-1.46, P=0.443). Favorable functional outcome (Cerebral Performance Category 1 or 2) by day 180 was 22.5% (27 of 120) in the hypothermic temperature control, compared with 23.7% (28 of 118) in the normothermia group (relative risk, 1.04 [95% CI, 0.78-1.44]; P=0.822). The study was prematurely terminated because of futility. CONCLUSIONS Hypothermic temperature control as compared with normothermia did not improve survival nor functional outcome at day 180 in patients presenting with coma after IHCA. The HACA in-hospital trial (Hypothermia After Cardiac Arrest in-hospital) was underpowered and may have failed to detect clinically important differences between hypothermic temperature control and normothermia. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT00457431.
Collapse
Affiliation(s)
- Sebastian Wolfrum
- Emergency Department (S.W., A.H.), University of Luebeck, Germany.,Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine (S.W., A.H., V.K., H.S.), University of Luebeck, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine (K.R., S.B., G.S., S.K.), University Medical Centre Hamburg-Eppendorf, Germany
| | - Alexia Hanebutte
- Emergency Department (S.W., A.H.), University of Luebeck, Germany.,Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine (S.W., A.H., V.K., H.S.), University of Luebeck, Germany
| | - Rüdiger Pfeifer
- Department of Internal Medicine 1, University Hospital of Jena, Germany (R.P.)
| | - Volkhard Kurowski
- Department of Intensive Care Medicine (K.R., S.B., G.S., S.K.), University Medical Centre Hamburg-Eppendorf, Germany.,Department of Cardiology and Intensive Care Medicine, DRK Hospital, Ratzeburg, Germany (V.K.)
| | - Reimer Riessen
- Department of Medicine, Medical Intensive Care Unit, University of Tübingen, Germany (R.R.)
| | - Anne Daubmann
- Institute of Medical Biometry and Epidemiology (A.D., E.B.-F.' K.W.), University Medical Centre Hamburg-Eppendorf, Germany
| | - Stephan Braune
- Department of Intensive Care Medicine (K.R., S.B., G.S., S.K.), University Medical Centre Hamburg-Eppendorf, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine (K.R., S.B., G.S., S.K.), University Medical Centre Hamburg-Eppendorf, Germany
| | - Eric Bibiza-Freiwald
- Institute of Medical Biometry and Epidemiology (A.D., E.B.-F.' K.W.), University Medical Centre Hamburg-Eppendorf, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology (A.D., E.B.-F.' K.W.), University Medical Centre Hamburg-Eppendorf, Germany.,German Centre for Cardiovascular Research (DZHK e.V.)' Partner Site Hamburg/Kiel/Lübeck' Hamburg' Germany (K.W.)
| | - Heribert Schunkert
- Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine (S.W., A.H., V.K., H.S.), University of Luebeck, Germany.,German Heart Center Munich, Department of Cardiology' Technical University of Munich' German Center for Cardiovascular Research (DZHK) - Munich Heart Alliance (H.S.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Germany (H.T.)
| | - Stefan Kluge
- Department of Intensive Care Medicine (K.R., S.B., G.S., S.K.), University Medical Centre Hamburg-Eppendorf, Germany
| | | |
Collapse
|
14
|
Lüsebrink E, Binzenhöfer L, Kellnar A, Scherer C, Schier J, Kleeberger J, Stocker TJ, Peterss S, Hagl C, Stark K, Petzold T, Fichtner S, Braun D, Kääb S, Brunner S, Theiss H, Hausleiter J, Massberg S, Orban M. Targeted Temperature Management in Postresuscitation Care After Incorporating Results of the TTM2 Trial. J Am Heart Assoc 2022; 11:e026539. [DOI: 10.1161/jaha.122.026539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrest still accounts for a substantial proportion of cardiovascular related deaths and is associated with a tremendous risk of neurological injury and, among the few survivors, poor quality of life. Critical determinants of survival and long‐term functional status after cardiac arrest are timely initiation of cardiopulmonary resuscitation and use of an external defibrillator for patients with a shockable rhythm. Outcomes are still far from satisfactory, despite ongoing efforts to improve cardiac arrest response systems, as well as elaborate postresuscitation algorithms. Targeted temperature management at the wide range between 32 °C and 36 °C has been one of the main therapeutic strategies to improve neurological outcome in postresuscitation care. This recommendation has been mainly based on 2 small randomized trials that were published 20 years ago. Most recent data derived from the TTM2 (Targeted Hypothermia Versus Targeted Normothermia After Out‐of‐Hospital Cardiac Arrest) trial, which included 1861 patients, challenge this strategy. It showed no benefit of targeted hypothermia at 33 °C over normothermia at 36 °C to 37.5 °C with fever prevention. Because temperature management at lower temperatures also correlated with an increased risk of side effects without any benefit in the TTM2 trial, a modification of the guidelines with harmonizing temperature management to normothermia might be necessary.
Collapse
Affiliation(s)
- Enzo Lüsebrink
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Leonhard Binzenhöfer
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Antonia Kellnar
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Clemens Scherer
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Johannes Schier
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Jan Kleeberger
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Thomas J. Stocker
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik Klinikum der Universität München Munich Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik Klinikum der Universität München Munich Germany
| | - Konstantin Stark
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Tobias Petzold
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stephanie Fichtner
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Daniel Braun
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stefan Kääb
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Stefan Brunner
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Hans Theiss
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Jörg Hausleiter
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Steffen Massberg
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Martin Orban
- Cardiac Intensive Care Unit Medizinische Klinik und Poliklinik I, Klinikum der Universität München Munich Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| |
Collapse
|
15
|
Temperature Control in Hypoxic-Ischemic Brain Injury—a Focused Update. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
16
|
Lee HJ, Shin J, You KM, Kwon WY, Kim KS, Jo YH, Park SM. Target temperature management versus normothermia without temperature feedback systems for out-of-hospital cardiac arrest survivors. J Int Med Res 2022; 50:3000605221126880. [PMID: 36177833 PMCID: PMC9528025 DOI: 10.1177/03000605221126880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The clinical benefit of automatic temperature control devices remains unclear. We investigated the outcomes of out-of-hospital cardiac arrest (OHCA) survivors who had undergone either target temperature management (TTM) with a temperature feedback system (TFS) or maintenance of normothermia without a TFS during post-resuscitation care. METHODS This study was a retrospective analysis of a multicenter prospective cohort of OHCA survivors who had received postcardiac arrest care from August 2014 to December 2018. The overlap propensity score weighting method was applied for adjustment between groups. RESULTS A total of 405 OHCA survivors were included. TTM with a TFS and normothermia without a TFS were applied to 318 and 87 patients, respectively. Fever events were more common in patients with normothermia without a TFS. After propensity score matching, no statistically significant differences were observed in the 1-month good neurologic outcome (odds ratio 0.99, 95% confidence interval [CI] 0.56-1.25) or survival rate (odds ratio 1.25, 95% CI 0.88-1.78). CONCLUSION No significant differences in the 1-month neurologic outcome were observed between patients receiving TTM with a TFS and those undergoing normothermia without a TFS.
Collapse
Affiliation(s)
- Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government – Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government – Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Kyoung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government – Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-ro Jongno-gu, Seoul, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Seung Min Park
- Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Best practice has been to cool these patients and control their temperature at a constant value in the range of 32-36 oC for at least 24 h. But the certainty of the evidence for this practice is increasingly being challenged. This review will summarize the evidence on key aspects of temperature control in comatose postcardiac arrest patients. RECENT FINDINGS The Targeted Temperature Management 2 (TTM-2) trial documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC vs. targeted normothermia. A systematic review and meta-analysis completed by the Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) concluded that temperature control with a target of 32-34 °C did not improve survival or favourable functional outcome after cardiac arrest. Two observational studies have documented an association between predicted moderate hypoxic-ischaemic brain injury and better outcome with temperature control at 33-34 oC compared with 35-36 oC. SUMMARY We suggest actively preventing fever by targeting a temperature 37.5 oC or less for those patients who remain comatose following return of spontaneous circulation (ROSC) after cardiac arrest.
Collapse
Affiliation(s)
- Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry
- Royal United Hospital, Bath
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| |
Collapse
|
18
|
Hillerson DB, Laine ME, Bissell BD, Mefford B. Contemporary targeted temperature management: Clinical evidence and controversies. Perfusion 2022; 38:666-680. [PMID: 35531914 DOI: 10.1177/02676591221076286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
Collapse
Affiliation(s)
- Dustin B Hillerson
- 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | |
Collapse
|
19
|
Nolan JP, Sandroni C, Andersen LW, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Lilja G, Morley PT, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone FS, Soar J. ERC-ESICM guidelines on temperature control after cardiac arrest in adults. Resuscitation 2022; 172:229-236. [PMID: 35131119 DOI: 10.1016/j.resuscitation.2022.01.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/11/2022]
Abstract
The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 hours. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.
Collapse
Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Bernd W Böttiger
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Peter T Morley
- University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa M Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| |
Collapse
|
20
|
Kjaergaard J, Schmidt H, Møller JE, Hassager C. The “Blood pressure and oxygenation targets in post resuscitation care, a randomized clinical trial”: design and statistical analysis plan. Trials 2022; 23:177. [PMID: 35209951 PMCID: PMC8867659 DOI: 10.1186/s13063-022-06101-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/10/2022] [Indexed: 12/27/2022] Open
Abstract
Background Comatose patients admitted after resuscitation from cardiac arrest have a significant risk of poor outcome due to hypoxic brain injury. While numerous studies have investigated and challenged the target temperature as the efficacious part of the guideline endorsed Targeted Temperature Management (TTM) protocols, our knowledge and how the remaining parts of the TTM are optimized remain sparse. The present randomized trial investigated two aspects of the TTM protocol: target blood pressure during the ICU stay and oxygenation during mechanical ventilation. Furthermore, the efficacy of device-based post-TTM fever management is addressed. Methods Investigator-initiated, dual-center, randomized clinical trial in comatose OHCA patients admitted to an intensive cardiac care unit. Patients are eligible for inclusion if unconscious, older than 18 years of age, and have return of spontaneous circulation for more than 20 min. Intervention: allocation 1:1:1:1 into a group defined by (a) blood pressure targets in double-blind intervention targeting a mean arterial blood pressure of 63 or 77 mmHg and (b) restrictive (9–10 kPa) or liberal (13–14 kPa) of arterial oxygen concentration during mechanical ventilation. As a subordinate intervention, device-based active fever management is discontinued after 36 h or 72. Patients will otherwise receive protocolized standard of care according to international guidelines, including targeted temperature management at 36 °C for 24 h, sedation with fentanyl and propofol, and multimodal neuro-prognostication. Primary endpoint: Discharge from hospital in poor neurological status (Cerebral Performance category 3 or 4) or death, whichever comes first. Secondary outcomes: Time to initiation of renal replacement therapy or death, neuron-specific enolase (NSE) level at 48 h, MOCA score at day 90, Modified Ranking Scale (mRS) and CPC at 3 months, NT-pro-BNP at 90 days, eGFR and LVEF at 90 days, daily cumulated vasopressor requirement during ICU stay, and need for a combination of vasopressors and inotropic agents or mechanical circulatory support. Discussion We hypothesize that low or high target blood pressure and restrictive and liberal oxygen administration will have an impact on mortality by reducing the risk and degree of hypoxic brain injury. This will be assessment neurological outcome and biochemical and neuropsychological testing after 90 days. Trial registration ClinicalTrials.gov NCT03141099. Registered on May 2017 (retrospectively registered)
Collapse
|
21
|
Sandroni C, Nolan JP, Andersen LW, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Lilja G, Morley PT, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone FS, Soar J. ERC-ESICM guidelines on temperature control after cardiac arrest in adults. Intensive Care Med 2022; 48:261-269. [PMID: 35089409 DOI: 10.1007/s00134-022-06620-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/06/2022] [Indexed: 11/05/2022]
Abstract
The aim of these guidelines is to provide evidence‑based guidance for temperature control in adults who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest, regardless of the underlying cardiac rhythm. These guidelines replace the recommendations on temperature management after cardiac arrest included in the 2021 post-resuscitation care guidelines co-issued by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). The guideline panel included thirteen international clinical experts who authored the 2021 ERC-ESICM guidelines and two methodologists who participated in the evidence review completed on behalf of the International Liaison Committee on Resuscitation (ILCOR) of whom ERC is a member society. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations. The panel provided suggestions on guideline implementation and identified priorities for future research. The certainty of evidence ranged from moderate to low. In patients who remain comatose after cardiac arrest, we recommend continuous monitoring of core temperature and actively preventing fever (defined as a temperature > 37.7 °C) for at least 72 h. There was insufficient evidence to recommend for or against temperature control at 32-36 °C or early cooling after cardiac arrest. We recommend not actively rewarming comatose patients with mild hypothermia after return of spontaneous circulation (ROSC) to achieve normothermia. We recommend not using prehospital cooling with rapid infusion of large volumes of cold intravenous fluids immediately after ROSC.
Collapse
Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy. .,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,Department of Intensive Care, Royal United Hospital, Bath, BA1 3NG, UK
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Alain Cariou
- Medical School, Cochin University Hospital (APHP), University of Paris, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Malmö, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium.,Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Peter T Morley
- University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa M Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| |
Collapse
|
22
|
Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
Collapse
Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| |
Collapse
|
23
|
Srinivasan V, Martin EG, Klemisch RJ. A Chilling Conclusion to the Hypothermia Debate?: November 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:690-692. [PMID: 34688442 DOI: 10.1016/j.annemergmed.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Emily G Martin
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Robert J Klemisch
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
24
|
Presciutti A, Perman SM. The evolution of hypothermia for neuroprotection after cardiac arrest: a history in the making. Ann N Y Acad Sci 2021; 1507:60-69. [PMID: 34554586 DOI: 10.1111/nyas.14676] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/09/2021] [Accepted: 07/21/2021] [Indexed: 12/01/2022]
Abstract
While much has been observed regarding hypothermia by way of environmental exposure, it is modern day medicine that deployed hypothermia as a therapeutic. From the early 1930s, when Temple Fay deployed "refrigeration" to treat pain, to the work of Wilfred Bigelow and Charles Drew, who utilized hypothermia in open heart surgery-the opportunities seemed endless. However, questions arose surrounding appropriate temperatures to achieve best outcomes and how to minimize adverse events, such as coagulopathy and infection. In the 1980s, hypothermia underwent a resurgence through Peter Safar's critical studies in large animals, which quickly translated into feasibility studies and the landmark trials of 2002 that paved the way for postcardiac arrest care as we currently know it. Through clinical and observational trials, modern-day targeted temperature management continues to adapt, striving to improve patient outcomes. While hypothermia has come a long way from the writings of Hippocrates, the ideal therapy has not yet been defined, and more work is needed. While the history is long, there is more to be written and advances to be achieved as we optimize the neuroprotective effects of hypothermia for comatose survivors of cardiac arrest.
Collapse
Affiliation(s)
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
25
|
Abstract
and that reference citations are not used in the synopsis. A devastating complication of cardiac arrest is hypoxic-ischemic injury, which leads to neurologic dysfunction and subsequently high mortality. Post-cardiac arrest care is complex and requires a multimodal approach to manage hemodynamic instability as well as provide neuroprotection. Targeted temperature management is recommended by the American Heart Association as well as the International Liaison Committee on Resuscitation as a class 1 intervention for postarrest neuroprotection in patients who remain unresponsive after cardiac arrest.
Collapse
Affiliation(s)
- Nicole Kupchik
- Nicole Kupchik Consulting, Inc., Evergreen Health, Seattle, WA, USA.
| |
Collapse
|
26
|
Factors Associated With Rebound Hyperthermia After Targeted Temperature Management in Out-of-Hospital Cardiac Arrest Patients: An Explorative Substudy of the Time-Differentiated Therapeutic Hypothermia in Out-of-Hospital Cardiac Arrest Survivors Trial. Crit Care Explor 2021; 3:e0458. [PMID: 34250498 PMCID: PMC8263323 DOI: 10.1097/cce.0000000000000458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To investigate rebound hyperthermia following targeted temperature management after cardiac arrest and its impact on functional outcome. DESIGN: Post hoc analysis. SETTING: Ten European ICUs. PATIENTS: Patients included in the time-differentiated therapeutic hypothermia in out-of-hospital cardiac arrest survivors trial treated with targeted temperature management at 33°C for 48 or 24 hours. Favorable functional outcome was defined as a Cerebral Performance Category of 1 or 2 at 6 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 338 included patients, 103 (30%) experienced rebound hyperthermia defined as a maximum temperature after targeted temperature management and rewarming exceeding 38.5°C. Using multivariate logistic regression analysis, increasing age (odds ratio, 0.97; 95% CI, 0.95–0.99; p = 0.02) and severe acute kidney injury within 72 hours of ICU admission (odds ratio, 0.35; 95% CI, 0.13–0.91; p = 0.03) were associated with less rebound hyperthermia, whereas male gender (odds ratio, 3.94; 95% CI, 1.34–11.57; p = 0.01), highest C-reactive protein value (odds ratio, 1.04; 95% CI, 1.01–1.07; p = 0.02), and use of mechanical chest compression during cardiopulmonary resuscitation (odds ratio, 2.00; 95% CI, 1.10–3.67; p = 0.02) were associated with more rebound hyperthermia. Patients with favorable functional outcome spent less time after rewarming over 38.5°C (2.5% vs 6.3%; p = 0.03), 39°C (0.14% vs 2.7%; p < 0.01), and 39.5°C (0.03% vs 0.71%; p < 0.01) when compared with others. Median time to rebound hyperthermia was longer in the unfavorable functional outcome group (33.2 hr; interquartile range, 14.3–53.0 hr vs 6.5 hr; interquartile range, 2.2–34.1; p < 0.01). In a predefined multivariate binary logistic regression model, rebound hyperthermia was associated with decreased odds of favorable functional outcome (odds ratio, 0.42; 95% CI, 0.22–0.79). CONCLUSIONS: One-third of targeted temperature management patients experience rebound hyperthermia, and it is more common in younger male patients with an aggravated inflammatory response and those treated with a mechanical chest compression device. Later onset of rebound hyperthermia and temperatures exceeding 38.5°C associate with unfavorable outcome.
Collapse
|
27
|
De Fazio C, Skrifvars MB, Søreide E, Grejs AM, Di Bernardini E, Jeppesen AN, Storm C, Kjaergaard J, Laitio T, Rasmussen BS, Tianen M, Kirkegaard H, Taccone FS. Quality of targeted temperature management and outcome of out-of-hospital cardiac arrest patients: A post hoc analysis of the TTH48 study. Resuscitation 2021; 165:85-92. [PMID: 34166741 DOI: 10.1016/j.resuscitation.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND No data are available on the quality of targeted temperature management (TTM) provided to out-of-hospital cardiac arrest (OHCA) patients and its association with outcome. METHODS Post hoc analysis of the TTH48 study (NCT01689077), which compared the effects of prolonged TTM at 33 °C for 48 h to standard 24-h TTM on neurologic outcome. Admission temperature, speed of cooling, rewarming rates, precision (i.e. temperature variability), overcooling and overshooting as post-cooling fever (i.e. >38.0 °C) were collected. A specific score, ranging from 1 to 9, was computed to define the "quality of TTM". RESULTS On a total of 352 patients, most had a moderate quality of TTM (n = 217; 62% - score 4-6), while 80 (23%) patients had a low quality of TTM (score 1-3) and only 52 (16%) a high quality of TTM (score 7-9). The proportion of patients with unfavorable neurological outcome (UO; Cerebral Performance Category of 3-5 at 6 months) was similar between the different quality of TTM groups (p = 0.90). Although a shorter time from arrest to target temperature and a lower proportion of time outside the target ranges in the TTM 48-h than in the TTM 24-h group, quality of TTM was similar between groups. Also, the proportion of patients with UO was similar between the different quality of TTM groups when TTM 48-h and TTM 24-h were compared. CONCLUSIONS In this study, high quality of TTM was provided to a small proportion of patients. However, quality of TTM was not associated with patients' outcome.
Collapse
Affiliation(s)
- Chiara De Fazio
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anders M Grejs
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Eugenio Di Bernardini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anni Nørgaard Jeppesen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, University of Turku, Turku, Finland
| | - Bodil Sten Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marjaana Tianen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Denmark
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
| |
Collapse
|
28
|
Huang M, Shoskes A, Migdady I, Amin M, Hasan L, Price C, Uchino K, Choi CW, Hernandez AV, Cho SM. Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)? J Intensive Care Med 2021; 37:157-167. [PMID: 34114481 DOI: 10.1177/08850666211018982] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. METHODS We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. RESULTS We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR (P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) (P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. CONCLUSIONS Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.
Collapse
Affiliation(s)
- Merry Huang
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Shoskes
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Ibrahim Migdady
- Division of Neurocritical Care, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Leen Hasan
- 7712University of Connecticut, Medicine Institute, Farmington, CT, USA
| | - Carrie Price
- Albert S. Cook Library, 1492Towson University, Towson, MD, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Chun Woo Choi
- Division of Cardiac Surgery, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, 15504University of Connecticut School of Pharmacy, Storrs, CT, USA.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
29
|
Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| |
Collapse
|
30
|
Neuromonitoring After Cardiac Arrest: Can Twenty-First Century Medicine Personalize Post Cardiac Arrest Care? Neurol Clin 2021; 39:273-292. [PMID: 33896519 DOI: 10.1016/j.ncl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac arrest survivors comprise a heterogeneous population, in which the etiology of arrest, systemic and neurologic comorbidities, and sequelae of post-cardiac arrest syndrome influence the severity of secondary brain injury. The degree of secondary neurologic injury can be modifiable and is influenced by factors that alter cerebral physiology. Neuromonitoring techniques provide tools for evaluating the evolution of physiologic variables over time. This article reviews the pathophysiology of hypoxic-ischemic brain injury, provides an overview of the neuromonitoring tools available to identify risk profiles for secondary brain injury, and highlights the importance of an individualized approach to post cardiac arrest care.
Collapse
|
31
|
Kim K, Lee BK, Park JS, Choi SP, Jang TC, Oh JS. Impact of controlled normothermia following hypothermic targeted temperature management for post-rewarming fever and outcomes in post-cardiac arrest patients: A propensity score-matched analysis from a multicentre registry. Resuscitation 2021; 162:284-291. [PMID: 33766661 DOI: 10.1016/j.resuscitation.2021.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
AIM OF THE STUDY We investigated whether controlled normothermia (CN) after the rewarming phase of targeted temperature management (TTM) is associated with preventing post-rewarming fever and outcomes 6 months after out-of-hospital cardiac arrest (OHCA). METHODS This was an analysis of a prospective registry comprising OHCA patients treated with TTM at 22 academic hospitals between October 2015 and December 2018. We calculated the incremental area under the curve (iAUC) for body temperature greater than or equal to 37.5 °C for each patient during the first 24 h after the end of rewarming. The relationships among CN and iAUC, 6-month survival and good neurological outcome were analysed. To minimize differences in the baseline characteristics of the patients, we used propensity score-matched analysis. RESULTS In total, 1144 patients were enrolled. After propensity score matching, 646 patients (comprising 323 pairs) were obtained. In the unmatched cohort, post-rewarming CN was significantly associated with a lower iAUC (0.34 [1.38] vs. 1.19 [2.27]; p < 0.001) but not 6-month survival (adjusted odds ratio (OR): 1.121; 95% confidence interval (CI): 0.836-1.504; p = 0.446) and good neurological outcome (adjusted OR: 1.030; 95% CI: 0.734-1.446; p = 0.863). The results were similar in the propensity score-matched cohort (0.38 [1.56] vs. 1.03 [2.21], p < 0.001, OR: 1.347, 95% CI: 0.989-1.835, p = 0.059 and OR: 1.280, 95% CI 0.925-1.772, p = 0.137, respectively). CONCLUSION Post-rewarming CN prevents high fever in the normothermia phase of TTM. However, our data suggest the lack of association between CN and the patient's 6-month survival and good neurological outcome.
Collapse
Affiliation(s)
- Kiwook Kim
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, 271 Cheonbo-ro, Uijeongbu-si, Gyeonggido 11765, Republic of Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, 160 Baekseo-ro, Dong-gu, Gwangju 61469, Republic of Korea.
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea.
| | - Seung Phil Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Eunpyeong St. Mary's Hospital, 1021, Tongil-ro, Eunpyeong-gu, Seoul 03312, Republic of Korea.
| | - Tae Chang Jang
- Department of Emergency Medicine, College of Medicine, Catholic University of Daegu, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Republic of Korea.
| | - Joo Suk Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, 271 Cheonbo-ro, Uijeongbu-si, Gyeonggido 11765, Republic of Korea.
| |
Collapse
|
32
|
Neuromarkers and neurological outcome in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia-experience from the HAnnover COoling REgistry (HACORE). PLoS One 2021; 16:e0245210. [PMID: 33411836 PMCID: PMC7790428 DOI: 10.1371/journal.pone.0245210] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/23/2020] [Indexed: 01/02/2023] Open
Abstract
Background Neuron-specific enolase (NSE) and S-100b have been used to assess neurological damage following out-of-hospital cardiac arrest (OHCA). Cut-offs were derived from small normothermic cohorts. Whether similar cut-offs apply to patients treated with hypothermia remained undetermined. Methods We investigated 251 patients with OHCA treated with hypothermia but without routine prognostication. Neuromarkers were determined at day 3, neurological outcome was assessed after hospital discharge by cerebral performance category (CPC). Results Good neurological outcome (CPC≤2) was achieved in 41%. Elevated neuromarkers, older age and absence of ST-segment elevation after ROSC were associated with increased mortality. Poor neurological outcome in survivors was additionally associated with history of cerebrovascular events, sepsis and higher admission lactate. Mean NSE was 33μg/l [16–94] vs. 119μg/l [25–406]; p<0.001, for survivors vs. non-survivors, and 21μg/l [16–29] vs. 40μg/l [23–98], p<0.001 for good vs. poor neurological outcome. S-100b was 0.127μg/l [0.063–0.360] vs. 0.772μg/l [0.121–2.710], p<0.001 and 0.086μg/l [0.061–0.122] vs. 0.138μg/l [0.090–0.271], p = 0.009, respectively. For mortality, thresholds of 36μg/l for NSE and 0.128μg/l for S-100b could be determined; for poor neurological outcome 33μg/l (NSE) and 0.123μg/l (S-100b), respectively. Positive predictive value for NSE was 81% (74–88) and 79% (71–85) for S-100b. Conclusions Thresholds for NSE and S-100b predicting mortality and poor neurological outcome are similar in OHCA patients receiving therapeutic hypothermia as in those reported before the era of hypothermia. However, both biomarkers do not have enough specificity to predict mortality or poor neurological outcome on their own and should only be additively used in clinical decision making.
Collapse
|
33
|
Abstract
OBJECTIVES To determine the association between targeted temperature management goal temperature of 33°C versus 36°C and neurologic outcome after out-of-hospital cardiac arrest. DESIGN This was a retrospective, before-and-after, cohort study. SETTING Urban, academic, level 1 trauma center from 2010 to 2017. PATIENTS Adults with nontraumatic out-of-hospital cardiac arrest who received targeted temperature management. INTERVENTIONS Our primary exposure was targeted temperature management goal temperature, which was changed from 33°C to 36°C in April of 2014 at the study hospital. Primary outcome was neurologically intact survival to discharge. Secondary outcomes included hospital mortality and care processes. MEASUREMENTS AND MAIN RESULTS Of 782 out-of-hospital cardiac arrest patients transported to the study hospital, 453 (58%) received targeted temperature management. Of these, 258 (57%) were treated during the 33°C period (targeted temperature management 33°C) and 195 (43%) were treated during the 36°C period (targeted temperature management 36°C). Patients treated during targeted temperature management 33°C were older (57 vs 52 yr; p < 0.05) and had more arrests of cardiac etiology (45% vs 35%; p < 0.05), but otherwise had similar baseline characteristics, including initial cardiac rhythm. A total of 40% of patients treated during targeted temperature management 33°C survived with favorable neurologic outcome, compared with 30% in the targeted temperature management 36°C group (p < 0.05). After adjustment for demographic and cardiac arrest characteristics, targeted temperature management 33°C was associated with increased odds of neurologically intact survival to discharge (odds ratio, 1.79; 95% CI, 1.09-2.94). Targeted temperature management 33°C was not associated with significantly improved hospital mortality. Targeted temperature management was implemented faster (1.9 vs 3.5 hr from 911 call; p < 0.001) and more frequently in the emergency department during the targeted temperature management 33°C period (87% vs 55%; p < 0.001). CONCLUSIONS Comatose, adult out-of-hospital cardiac arrest patients treated during the targeted temperature management 33°C period had higher odds of neurologically intact survival to hospital discharge compared with those treated during the targeted temperature management 36°C period. There was no significant difference in hospital mortality.
Collapse
|
34
|
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
35
|
Rozier R, Bruckert V, Orban JC. Therapeutic hypothermia after cardiac arrest: We have found the missing piece puzzle! Anaesth Crit Care Pain Med 2020; 38:573-574. [PMID: 31785699 DOI: 10.1016/j.accpm.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Romain Rozier
- Pôle Anesthésie Réanimations Urgences, Centre Hospitalier Universitaire de Nice, 30 Voie Romaine, 06006 Nice, France
| | - Vincent Bruckert
- Pôle Anesthésie Réanimations Urgences, Centre Hospitalier Universitaire de Nice, 30 Voie Romaine, 06006 Nice, France
| | - Jean-Christophe Orban
- Pôle Anesthésie Réanimations Urgences, Centre Hospitalier Universitaire de Nice, 30 Voie Romaine, 06006 Nice, France.
| |
Collapse
|
36
|
The cold truth about postcardiac arrest targeted temperature management: 33°C vs. 36°C. Nursing 2020; 50:24-30. [PMID: 32947373 DOI: 10.1097/01.nurse.0000697148.62653.1a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article provides nurses with up-to-date evidence to empower them in contributing to the 33°C versus 36°C discussion in postcardiac arrest targeted temperature management (TTM). Presented in debate format, this article addresses the pros and cons of various target temperatures, examines the evidence around TTM, and applies it to clinical scenarios.
Collapse
|
37
|
Early Post-Rewarming Fever Is Associated with Favorable 6-Month Neurologic Outcomes in Patients with Out-Of-Hospital Cardiac Arrest: A Multicenter Registry Study. J Clin Med 2020; 9:jcm9092927. [PMID: 32927857 PMCID: PMC7565524 DOI: 10.3390/jcm9092927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
We investigated the association between post-rewarming fever (PRF) and 6-month neurologic outcomes in cardiac arrest survivors. This was a multicenter study based on a registry of comatose adult (≥18 years) out-of-hospital cardiac arrest (OHCA) survivors who underwent targeted temperature management between October 2015 to December 2018. PRF was defined as peak temperature ≥ 38.0 °C within 72 h after completion of rewarming, and PRF timing was categorized as within 24, 24–48, and 48–72 h epochs. The primary outcome was neurologic outcomes at six months after cardiac arrest. Unfavorable neurologic outcome was defined as cerebral performance categories three to five. A total of 1031 patients were included, and 642 (62.3%) had unfavorable neurologic outcomes. PRF developed in 389 (37.7%) patients in 72 h after rewarming: within 24 h in 150 (38.6%), in 24–48 h in 155 (39.8%), and in 48–72 h in 84 (21.6%). PRF was associated with improved neurologic outcomes (odds ratio (OR), 0.633; 95% confidence interval (CI), 0.416–0.963). PRF within 24 h (OR, 0.355; 95% CI, 0.191–0.659), but not in 24–48 h or 48–72 h, was associated with unfavorable neurologic outcomes. Early PRF within 24 h after rewarming was associated with favorable neurologic outcomes.
Collapse
|
38
|
Kuroda Y, Kawakita K. Targeted temperature management for postcardiac arrest syndrome. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.200001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
39
|
Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
Collapse
Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
| |
Collapse
|
40
|
Merkulova IA, Avetisyan EA, Terenicheva MA, Pevsner DV, Shakhnovich RM. [Therapeutic Hypothermia in a Cardiac Arrest: Complicated Questions and Unsolved Problems]. ACTA ACUST UNITED AC 2020; 60:104-110. [PMID: 32345206 DOI: 10.18087/cardio.2020.2.n690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022]
Abstract
The article aims to review the main trials, meta-analyses and guidelines regarding to various practical aspects and unsolved questions of an appliance of the therapeutic hypothermia in out-of-hospital and in-hospital cardiac arrest.
Collapse
Affiliation(s)
- I A Merkulova
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - E A Avetisyan
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - M A Terenicheva
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - D V Pevsner
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| | - R M Shakhnovich
- National Medical Research Center of Cardiology, Ministry of Healthcare Russian Federation, Moscow
| |
Collapse
|
41
|
Taccone FS, Picetti E, Vincent JL. High Quality Targeted Temperature Management (TTM) After Cardiac Arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:6. [PMID: 31907075 PMCID: PMC6945621 DOI: 10.1186/s13054-019-2721-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
Targeted temperature management (TTM) is a complex intervention used with the aim of minimizing post-anoxic injury and improving neurological outcome after cardiac arrest. There is large variability in the devices used to achieve cooling and in protocols (e.g., for induction, target temperature, maintenance, rewarming, sedation, management of post-TTM fever). This variability can explain the limited benefits of TTM that have sometimes been reported. We therefore propose the concept of “high-quality TTM” as a way to increase the effectiveness of TTM and standardize its use in future interventional studies.
Collapse
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium.
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Jean-Louis Vincent
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Hopital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| |
Collapse
|
42
|
Postresuscitation Care after Out-of-hospital Cardiac Arrest: Clinical Update and Focus on Targeted Temperature Management. Anesthesiology 2020; 131:186-208. [PMID: 31021845 DOI: 10.1097/aln.0000000000002700] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Out-of-hospital cardiac arrest is a major cause of mortality and morbidity worldwide. With the introduction of targeted temperature management more than a decade ago, postresuscitation care has attracted increased attention. In the present review, we discuss best practice hospital management of unconscious out-of-hospital cardiac arrest patients with a special focus on targeted temperature management. What is termed post-cardiac arrest syndrome strikes all organs and mandates access to specialized intensive care. All patients need a secured airway, and most patients need hemodynamic support with fluids and/or vasopressors. Furthermore, immediate coronary angiography and percutaneous coronary intervention, when indicated, has become an essential part of the postresuscitation treatment. Targeted temperature management with controlled sedation and mechanical ventilation is the most important neuroprotective strategy to take. Targeted temperature management should be initiated as quickly as possible, and according to international guidelines, it should be maintained at 32° to 36°C for at least 24 h, whereas rewarming should not increase more than 0.5°C per hour. However, uncertainty remains regarding targeted temperature management components, warranting further research into the optimal cooling rate, target temperature, duration of cooling, and the rewarming rate. Moreover, targeted temperature management is linked to some adverse effects. The risk of infection and bleeding is moderately increased, as is the risk of hypokalemia and magnesemia. Circulation needs to be monitored invasively and any deviances corrected in a timely fashion. Outcome prediction in the individual patient is challenging, and a self-fulfilling prophecy poses a real threat to early prognostication based on clinical assessment alone. Therefore, delayed and multimodal prognostication is now considered a key element of postresuscitation care. Finally, modern postresuscitation care can produce good outcomes in the majority of patients but requires major diagnostic and therapeutic resources and specific training. Hence, recent international guidelines strongly recommend the implementation of regional prehospital resuscitation systems with integrated and specialized cardiac arrest centers.
Collapse
|
43
|
Response to commentary on “Therapeutic hypothermia attenuates paraplegia and neuronal damage in the lumbar spinal cord in a rat model of asphyxial cardiac arrest” by Lee et al.,. J Therm Biol 83 (2019) 1–7.". J Therm Biol 2020; 87:102455. [DOI: 10.1016/j.jtherbio.2019.102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/18/2022]
|
44
|
Akin M, Sieweke JT, Zauner F, Garcheva V, Tongers J, Napp LC, Friedrich L, Treptau J, Bahntje MU, Flierl U, Sedding DG, Bauersachs J, Schäfer A. Mortality in Patients With Out-of-Hospital Cardiac Arrest Undergoing a Standardized Protocol Including Therapeutic Hypothermia and Routine Coronary Angiography: Experience From the HACORE Registry. JACC Cardiovasc Interv 2019; 11:1811-1820. [PMID: 30236353 DOI: 10.1016/j.jcin.2018.06.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/07/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to analyze the impact of mandatory therapeutic hypothermia and cardiac catheterization in the absence of overt noncardiac cause of arrest as part of the Hannover Cardiac Resuscitation Algorithm before intensive care admission. BACKGROUND Despite advanced therapies, out-of-hospital cardiac arrest (OHCA) is still associated with high mortality rates. Recently, the TTM (Target Temperature Management 33°C Versus 36°C After Out-of-Hospital Cardiac Arrest)-trial caused severe uncertainty about the efficacy of and need for therapeutic hypothermia. Furthermore, the role of early coronary angiography in OHCA survivors without ST-segment elevation remains undetermined. METHODS In the HACORE (HAnnover Cooling REgistry) we investigated 233 consecutive patients (median age 64 [interquartile range: 53 to 74] years) with OHCA admitted to our institution between January 2011 and December 2015 who were treated according to the algorithm. RESULTS A total of 73% had ventricular fibrillation as primary rhythm. Return of spontaneous circulation was achieved after 20 (interquartile range: 10 to 30) min. Immediate percutaneous coronary angiography was performed in 96% and coronary angioplasty in 59% of all cases. ST-segment elevation was present in 47%. Critical coronary stenosis requiring percutaneous coronary intervention was present in 67% of patients with and 52% of patients without ST-segment elevation. Overall 30-day intrahospital mortality in this real-world registry was 37%. Patients in our local registry who matched the inclusion/exclusion criteria of the TTM-trial (n = 145) had a markedly lower 30-day mortality (27%) compared with the published trial (44%). CONCLUSIONS Standardized treatment of patients with OHCA following a strict protocol incorporating computed tomography, cardiac catheterization and revascularization, liberal use of active hemodynamic support in presence of shock, and mandatory therapeutic hypothermia results in mortality rates lower than previously reported.
Collapse
Affiliation(s)
- Muharrem Akin
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan-Thorben Sieweke
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Florian Zauner
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Vera Garcheva
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jörn Tongers
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Friedrich
- Department of Anaesthesiology, Hannover Medical School, Hannover, Germany
| | - Jens Treptau
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Max-Udo Bahntje
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ulrike Flierl
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Daniel G Sedding
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Centre, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
| |
Collapse
|
45
|
Kim YS, Cho JH, Shin MC, Park Y, Park CW, Tae HJ, Cho JH, Kim IS, Lee TK, Park YE, Ahn JH, Park JH, Kim DW, Won MH, Lee JC. Effects of regional body temperature variation during asphyxial cardiac arrest on mortality and brain damage in a rat model. J Therm Biol 2019; 87:102466. [PMID: 31999601 DOI: 10.1016/j.jtherbio.2019.102466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 01/19/2023]
Abstract
To date, hypothermia has focused on improving rates of resuscitation to increase survival in patients sustaining cardiac arrest (CA). Towards this end, the role of body temperature in neuronal damage or death during CA needs to be determined. However, few studies have investigated the effect of regional temperature variation on survival rate and neurological outcomes. In this study, adult male rats (12 week-old) were used under the following four conditions: (i) whole-body normothermia (37 ± 0.5 °C) plus (+) no asphyxial CA, (ii) whole-body normothermia + CA, (iii) whole-body hypothermia (33 ± 0.5 °C)+CA, (iv) body hypothermia/brain normothermia + CA, and (v) brain hypothermia/body normothermia + CA. The survival rate after resuscitation was significantly elevated in groups exposed to whole-body hypothermia plus CA and body hypothermia/brain normothermia plus CA, but not in groups exposed to whole-body normothermia combined with CA and brain hypothermia/body normothermia plus CA. However, the group exposed to hypothermia/brain normothermia combined with CA exhibited higher neuroprotective effects against asphyxial CA injury, i.e. improved neurological deficit and neuronal death in the hippocampus compared with those involving whole-body normothermia combined with CA. In addition, neurological deficit and neuronal death in the group of rat exposed to brain hypothermia/body normothermia and CA were similar to those in the rats subjected to whole-body normothermia and CA. In brief, only brain hypothermia during CA was not associated with effective survival rate, neurological function or neuronal protection compared with those under body (but not brain) hypothermia during CA. Our present study suggests that regional temperature in patients during CA significantly affects the outcomes associated with survival rate and neurological recovery.
Collapse
Affiliation(s)
- Yoon Sung Kim
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea; Department of Emergency Medicine, Samcheok Medical Center, Samcheok, Kangwon, 25920, Republic of Korea
| | - Jun Hwi Cho
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Myoung-Cheol Shin
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Yoonsoo Park
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Chan Woo Park
- Department of Emergency Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Hyun-Jin Tae
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - Jeong Hwi Cho
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - In-Shik Kim
- Bio-Safety Research Institute, College of Veterinary Medicine, Chonbuk National University, Iksan, Chonbuk, 54596, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Young Eun Park
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea
| | - Ji Hyeon Ahn
- Department of Biomedical Science and Research Institute for Bioscience and Biotechnology, Hallym University, Chuncheon, Gangwon, 24252, Republic of Korea
| | - Joon Ha Park
- Department of Anatomy, College of Korean Medicine, Dongguk University, Gyeongju, Gyeongbuk, 38066, Republic of Korea
| | - Dae Won Kim
- Department of Biochemistry and Molecular Biology, Research Institute of Oral Sciences, College of Dentistry, Kangnung-Wonju National University, Gangneung, Gangwon, 25457, Republic of Korea
| | - Moo-Ho Won
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
| | - Jae-Chul Lee
- Department of Neurobiology, School of Medicine, Kangwon National University, Chuncheon, Gangwon, 24341, Republic of Korea.
| |
Collapse
|
46
|
Hifumi T, Inoue A, Kokubu N, Hase M, Yonemoto N, Kuroda Y, Kawakita K, Sawano H, Tahara Y, Nishioka K, Shirai S, Hazui H, Arimoto H, Kashiwase K, Kasaoka S, Motomura T, Yasuga Y, Yokoyama H, Nagao K, Nonogi H. Association between rewarming duration and neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia. Resuscitation 2019; 146:170-177. [PMID: 31394154 DOI: 10.1016/j.resuscitation.2019.07.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 02/08/2023]
Abstract
AIM The European Resuscitation Council guidelines recommend a slow rate of rewarming of 0.25 °C/h-0.5 °C/h for out-of-hospital cardiac arrest (OHCA) patients receiving therapeutic hypothermia (TH). Conversely, a very slow rewarming of 1 °C/day is generally applied in Japan. The rewarming duration ranged from less than 24 h up to more than 50 h. No randomized control trials have examined the optimal rewarming speed for TH in OHCA patients. Therefore, we examined the association between the rewarming duration and neurological outcomes in OHCA patients who received TH. METHODS This study was a secondary analysis of the Japanese Population-based Utstein-style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia (J-PULSE-HYPO) study registry, a multicenter prospective cohort study. Patients suffering from OHCA who received TH (target temperature, 34 °C) after the return of spontaneous circulation from 2005 to 2011 in 14 hospitals throughout Japan were enrolled. The rewarming duration was defined as the time from the beginning of rewarming at a target temperature of 34 °C until reaching 36 °C. The primary outcome was an unfavorable neurological outcome at hospital discharge, i.e., a cerebral performance category of 3-5. RESULTS The J-PULSE-HYPO study enrolled 452 OHCA patients. Of these, 328 were analyzed; 79.9% survived to hospital discharge, of which 56.4% had a favorable neurological outcome. Multivariable logistic regression analysis revealed that the rewarming duration was independently associated with unfavorable neurological outcomes [odds ratio (per 5 h), 0.89; 95% confidence interval, 0.79-0.99; p = 0.032]. CONCLUSION A longer rewarming duration was significantly associated with and was an independent predictor of favorable neurological outcomes in OHCA patients who received TH.
Collapse
Affiliation(s)
- Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan; Emergency Medical Center, Kagawa University Hospital, Japan.
| | - Akihiko Inoue
- Emergency Medical Center, Kagawa University Hospital, Japan; Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Japan
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University, Japan
| | | | - Naohiro Yonemoto
- Department of Biostatistics, Kyoto University School of Public Health, Japan
| | | | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Japan
| | - Hirotaka Sawano
- Senri Critical Care Medical Center, Saiseikai Senri Hospital, Japan
| | - Yoshio Tahara
- Division of Cardiovascular Care Unit, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kenji Nishioka
- Department of Cardiology, Hiroshima City Hospital, Japan
| | | | - Hiroshi Hazui
- Emergency Medicine, Osaka Mishima Emergency and Critical Care Center, Japan
| | - Hideki Arimoto
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Japan
| | - Kazunori Kashiwase
- Department of Internal Medicine, Division of Coronary Heart Disease, Hyogo College of Medicine, Japan
| | - Shunji Kasaoka
- Department of Emergency and General Medicine, Kumamoto University Hospital, Japan
| | - Tomokazu Motomura
- Shock & Trauma Center, Chiba Hokusoh Hospital, Nippon Medical School, Japan
| | - Yuji Yasuga
- Department of Cardiology, Sumitomo hospital, Japan
| | | | - Ken Nagao
- Cardiovascular Center, Nihon University Hospital, Japan
| | | | | |
Collapse
|
47
|
Walker AC, Johnson NJ. Targeted Temperature Management and Postcardiac arrest Care. Emerg Med Clin North Am 2019; 37:381-393. [PMID: 31262410 DOI: 10.1016/j.emc.2019.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite recent advances, care of the post-cardiac arrest patient remains a challenge. In this article, the authors discuss an approach to the initial care of post-cardiac arrest patients with particular focus on targeted temperature management (TTM). The article starts with history, physiologic rationale, and the major randomized controlled trials that have shaped guidelines for post-cardiac arrest care. It also reviews controversial topics, including TTM for nonshockable rhythms, TTM dose, and surface versus endovascular cooling. The article concludes with a brief review of other key aspects of post-arrest care: coronary angiography, hemodynamic optimization, ventilator management, and prognostication.
Collapse
Affiliation(s)
- Amy C Walker
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
48
|
Naiman M, Markota A, Hegazy A, Dingley J, Kulstad E. Retrospective Analysis of Esophageal Heat Transfer for Active Temperature Management in Post-cardiac Arrest, Refractory Fever, and Burn Patients. Mil Med 2019; 183:162-168. [PMID: 29635598 PMCID: PMC6490293 DOI: 10.1093/milmed/usx207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 01/02/2018] [Indexed: 01/16/2023] Open
Abstract
Core temperature management is an important aspect of critical care; preventing unintentional hypothermia, reducing fever, and inducing therapeutic hypothermia when appropriate are each tied to positive health outcomes. The purpose of this study is to evaluate the performance of a new temperature management device that uses the esophageal environment to conduct heat transfer. De-identified patient data were aggregated from three clinical sites where an esophageal heat transfer device (EHTD) was used to provide temperature management. The device was evaluated against temperature management guidelines and best practice recommendations, including performance during induction, maintenance, and cessation of therapy. Across all active cooling protocols, the average time-to-target was 2.37 h and the average maintenance phase was 22.4 h. Patients spent 94.9% of the maintenance phase within ±1.0°C and 67.2% within ±0.5°C (574 and 407 measurements, respectively, out of 605 total). For warming protocols, all of the patient temperature readings remained above 36°C throughout the surgical procedure (average 4.66 h). The esophageal heat transfer device met performance expectations across a range of temperature management applications in intensive care and burn units. Patients met and maintained temperature goals without any reported adverse events.
Collapse
Affiliation(s)
- Melissa Naiman
- Collaborative for Advanced Research, Design, and Evaluation, University of Illinois at Chicago, 2121W. Taylor Street #540, Chicago, IL 60612
| | - Andrej Markota
- Medical Intensive Care Unit, University Medical Center Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - Ahmed Hegazy
- Department of Anesthesia & Perioperative Medicine, University Hospital, Rm. C3-108, London, ON, Canada N6A 5A5
| | - John Dingley
- Welsh Centre for Burns, ABM University Health Board, Morriston Hospital, Swansea SA6 6NL, UK
| | - Erik Kulstad
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| |
Collapse
|
49
|
Vattanavanit V, Uppanisakorn S, Nilmoje T. Post out-of-hospital cardiac arrest care in a tertiary care center in southern Thailand: From emergency department to intensive care unit. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919830896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Out-of-hospital cardiac arrest results in a high mortality rate. The 2015 American Heart Association guideline for post-cardiac arrest was launched and adopted into our institutional policy. Objectives: We aimed to evaluate post-cardiac arrest care and compare the results with the 2015 American Heart Association guideline and clinical outcomes of out-of-hospital cardiac arrest patients. Methods Included in this study were all adult patients who survived out-of-hospital cardiac arrest and were admitted to the Medical Intensive Care Unit of Songklanagarind Hospital, Thailand. The retrospective review was from 1 January 2016 to 31 December 2017. Results: From a total of 161 post-cardiac arrest patients admitted to the medical intensive care unit, 69 out-of-hospital cardiac arrest patients were identified. The most common cause of arrest was presumed cardiac in origin (45.0%) in which the majority was acute myocardial infarction (67.8%). Coronary intervention and targeted temperature management were performed in 27.5% and 13% of all out-of-hospital cardiac arrest patients, respectively. Survival to hospital discharge was 42%. Independent factors associated with survival to discharge were shockable rhythms, lower adrenaline doses, and the absence of hypotension at medical intensive care unit admission. Conclusion: Compliance with the 2015 American Heart Association post-cardiac arrest care guideline was low in our institution, especially in coronary intervention and targeted temperature management.
Collapse
Affiliation(s)
- Veerapong Vattanavanit
- Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | | | - Thanapon Nilmoje
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| |
Collapse
|
50
|
Kuroda Y. Post-cardiac Arrest Syndrome (PCAS). Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|