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Andersen LW, Holmberg MJ, Nolan JP, Soar J, Granfeldt A. Conflicting guidelines: a commentary on the recent European Society for Emergency Medicine and European Society of Anaesthesiology and Intensive Care guidelines on temperature control after cardiac arrest. Eur J Anaesthesiol 2024; 41:468-472. [PMID: 38845576 DOI: 10.1097/eja.0000000000002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2024]
Affiliation(s)
- Lars W Andersen
- From the Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus (LWA, MJH, AG), Prehospital Emergency Medical Services, Central Denmark Region (LWA), Department of Anesthesiology and Intensive Care Medicine, Viborg Regional Hospital, Viborg, Denmark (LWA), University of Warwick, Warwick Medical School, Coventry (JPN), Department of Anaesthesia, the Royal United Hospital, Bath (JPN) and Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom (JS)
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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024; 48:341-355. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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Ali MA, Raju MP, Lyngaas T, Raju V, Jatla S, Nguyen N, Vora N, Beeram M, Govande V. Cooling Under a Blanketrol System Versus Cooling With an Arctic Sun Thermoregulation System (CATS) for Neonates Undergoing Therapeutic Hypothermia. Cureus 2024; 16:e59634. [PMID: 38832150 PMCID: PMC11146445 DOI: 10.7759/cureus.59634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
Background Despite evidence suggesting improved outcomes in neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH), data on the impact of temperature variability during cooling and its association with clinical outcomes remain limited. Objective To compare the efficacy and ease of use of two different cooling systems, the Arctic Sun (Medivance, Inc., Louisville, CO) vs. the Blanketrol III (Gentherm Medical, Cincinnati, OH) on achieving TH, temperature variability, and clinical outcomes in neonates with HIE undergoing TH. Methods This study was conducted at the Baylor Scott and White Medical Center's Level IV NICU. The study employed a retrospective cohort design, comparing infants treated with the Arctic Sun device (from December 2020 to August 2021) to a historical cohort treated with the Blanketrol system (from January 2017 to November 2020). Both groups were evaluated for clinical characteristics, patients' outcomes, and ease of use of the cooling devices. Ease of use was assessed through a self-developed survey administered to NICU nurses. Core body temperatures throughout the cooling course were documented at four-hour intervals, including induction, maintenance, and rewarming phases. Results Twenty-two infants were cooled using the Arctic Sun system, and 44 infants were cooled with the Blanketrol device. Median birth weight and gestational age were comparable. There were no significant differences in one-minute and five-minute appearance, pulse, grimace, activity, and respiration (APGAR) scores. The Arctic Sun group had a significantly higher rate of maternal morbidities, including diabetes and placental abruption. Although the median temperature achieved with both devices was 33.5°C, temperature variability was significantly greater with the Blanketrol device (p = 0.03). Thrombocytopenia rates were statistically different between the groups (9% in Arctic Sun vs. 38% in Blanketrol, p = 0.001). Although the Blanketrol group had higher rates of disseminated intravascular coagulation (48% vs. 37%), hypercalcemia (23% vs. 5%), and subcutaneous fat necrosis (7% vs. 5%), these differences were not statistically significant. A nurses' survey on ease of use revealed a strong preference for the Arctic Sun cooling system. Over 85% of nurses found it easier to learn and set up and required less manual intervention than the Blanketrol device. Conclusions Gel adhesive pad-based TH is a potentially superior modality to traditional water-circulating cooling devices. These pads offer advantages in user-friendliness, improved temperature control precision, and potentially reduced adverse event profiles.
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Affiliation(s)
- Mahmoud A Ali
- Neonatology, West Virginia University, Morgantown, USA
| | | | - Tara Lyngaas
- Neonatal Intensive Care Unit (NICU), Baylor Scott & White Health, Temple, USA
| | - Venkata Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Shreya Jatla
- Pediatrics, University of Texas at Austin, Temple, USA
| | - Nguyen Nguyen
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
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Gao Y, Li M, Jiang M, Zhang Y, Ji X. A narrative review of intravascular catheters in therapeutic hypothermia. Brain Circ 2024; 10:11-20. [PMID: 38655445 PMCID: PMC11034446 DOI: 10.4103/bc.bc_32_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/22/2023] [Accepted: 07/27/2023] [Indexed: 04/26/2024] Open
Abstract
Therapeutic hypothermia (TH) has been regarded as a promising neuroprotective method for acute ischemic stroke (AIS) for decades. During the development of TH, most researchers focused on improving hypothermic benefits by optimizing treatment processes and conditions. Intravenous thrombolysis and endovascular thrombectomy, for instance, have been introduced into AIS treatment. However, the lack of specialized intervention consumables, especially intervention catheter, led to inaccurate and uncontrolled hypothermic temperature, limited the efficacy of TH. In this review, intervention catheters as well as accessory equipment utilized in TH treatment has been summarized. Hopefully, this review may inspire the future development of TH specialized intervention catheter, enhance the outcome of TH, and neuroprotective efficacy in AIS.
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Affiliation(s)
- Yuan Gao
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, China
- Research Institute for Frontier Science, Beihang University, Beijing, China
| | - Ming Li
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Miaowen Jiang
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, China
- Research Institute for Frontier Science, Beihang University, Beijing, China
| | - Yang Zhang
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, China
- Research Institute for Frontier Science, Beihang University, Beijing, China
- Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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Sharda SC, Bhatia MS, Jakhotia RR, Behera A, Saroch A, Pannu AK, Kumar HM. Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis. Brain Circ 2023; 9:185-193. [PMID: 38020958 PMCID: PMC10679624 DOI: 10.4103/bc.bc_18_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 12/01/2023] Open
Abstract
AIM The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation. METHODS In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes. RESULTS One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%). CONCLUSIONS After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.
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Affiliation(s)
- Saurabh C. Sharda
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mandip Singh Bhatia
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit R. Jakhotia
- Department of Medicine, Chaitanya Hospital, Pune, Maharashtra, India
| | - Ashish Behera
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - H Mohan Kumar
- Department of Internal Medicine, Division of Acute Care and Emergency Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Wang IT, Wang CJ, Chen CH, Yang SH, Chen CY, Huang YC, Lin CY, Wu CL. Optimal Timing of Targeted Temperature Management for Post-Cardiac Arrest Syndrome: Is Sooner Better? J Clin Med 2023; 12:jcm12072628. [PMID: 37048710 PMCID: PMC10095041 DOI: 10.3390/jcm12072628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Targeted temperature management (TTM) is often considered to improve post-cardiac arrest patients’ outcomes. However, the optimal timing to initiate cooling remained uncertain. This retrospective analysis enrolled all non-traumatic post-cardiac arrest adult patients with either out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA) who received TTM from July 2015 to July 2021 at our hospital. The values of time delay before TTM and time to target temperature were divided into three periods according to optimal cut-off values identified using receiver operating characteristic curve analysis. A total of 177 patients were enrolled. A shorter time delay before TTM (pre-induction time) was associated with a lower survival chance at 28 days (32.00% vs. 54.00%, p = 0.0279). Patients with a longer cooling induction time (>440 minis) had better neurological outcomes (1.58% vs. 1.05%; p = 0.001) and survival at 28 days (58.06% vs. 29.25%; p = 0.006). After COX regression analysis, the influence of pre-induction time on survival became insignificant, but patients who cooled slowest still had a better chance of survival at 28 days. In conclusion, a shorter delay before TTM was not associated with better clinical outcomes. However, patients who took longer to reach the target temperature had better hospital survival and neurological outcomes than those who were cooled more rapidly. A further prospective study was warranted to evaluate the appropriate time window of TTM.
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Affiliation(s)
- I-Ting Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Department of Medicine, MacKay Memorial College, New Taipei City 25245, Taiwan
| | - Chieh-Jen Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Department of Medicine, MacKay Memorial College, New Taipei City 25245, Taiwan
- Correspondence: ; Tel.: +886-2-28094661 (ext. 2331)
| | - Chao-Hsien Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Department of Medicine, MacKay Memorial College, New Taipei City 25245, Taiwan
| | - Sheng-Hsiung Yang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Ph.D. Program in Translational Medicine, National Taiwan University and Academia Sinica, Taipei 11529, Taiwan
| | - Chun-Yen Chen
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
| | - Yen-Chun Huang
- Graduate Institute of Business Administration, Fu Jen Catholic University, New Taipei City 242062, Taiwan
- Artificial Intelligence Development Center, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Chang-Yi Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
- Department of Medicine, MacKay Memorial College, New Taipei City 25245, Taiwan
| | - Chien-Liang Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan
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Zhou R, Li J, Wang R, Chen Z, Zhou F. Moderate systemic therapeutic hypothermia is insufficient to protect blood-spinal cord barrier in spinal cord injury. Front Neurol 2022; 13:1041099. [DOI: 10.3389/fneur.2022.1041099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022] Open
Abstract
Blood–spinal cord barrier (BSCB) disruption is a pivotal event in spinal cord injury (SCI) that aggravates secondary injury but has no specific treatment. Previous reports have shown that systemic therapeutic hypothermia (TH) can protect the blood–brain barrier after brain injury. To verify whether a similar effect exists on the BSCB after SCI, moderate systemic TH at 32°C was induced for 4 h on the mice with contusion-SCI. In vivo two-photon microscopy was utilized to dynamically monitor the BSCB leakage 1 h after SCI, combined with immunohistochemistry to detect BSCB leakage at 1 and 4 h after SCI. The BSCB leakage was not different between the normothermia (NT) and TH groups at both the in vivo and postmortem levels. The expression of endothelial tight junctions was not significantly different between the NT and TH groups 4 h after SCI, as detected by capillary western blotting. The structural damage of the BSCB was examined with immunofluorescence, but the occurrence of junctional gaps was not changed by TH 4 h after SCI. Our results have shown that moderate systemic TH induced for 4 h does not have a protective effect on the disrupted BSCB in early SCI. This treatment method has a low value and is not recommended for BSCB disruption therapy in early SCI.
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Dibu JR, Haque R, Shoshan S, Abulhasan YB. Treatment of Fever in Neurologically Critically Ill Patients. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00732-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Javanbakht M, Mashayekhi A, Hemami MR, Branagan-Harris M, Keeble TR, Yaghoubi M. Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England. PHARMACOECONOMICS - OPEN 2022; 6:549-562. [PMID: 35503202 PMCID: PMC9283555 DOI: 10.1007/s41669-022-00333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been shown to improve neurological outcomes and survival in patients resuscitated from cardiac arrest; however, the cost effectiveness of multiple TTM methods is not well studied. OBJECTIVE This study aimed to evaluate the cost effectiveness of intravascular temperature management (IVTM) using Thermogard XP compared with surface cooling methods after cardiac arrest in the England from the perspectives of the UK national health service and Personal Social Services. METHODS We developed a multi-state Markov model that evaluated IVTM (Thermogard XP) compared with surface cooling using two different devices (Blanketrol III and Arctic Sun 5000) over a short-term and lifetime time horizon. Model input parameters were obtained from the literature and local databases. We assumed a hypothetical cohort of 1000 patients who required TTM after cardiac arrest per year in the England. The outcomes were costs (in £, year 2019 values) and quality-adjusted life-years (QALYs), discounted at 3.5% annually. Deterministic and probabilistic sensitivity analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results. RESULTS The cost-effectiveness analysis determined that Thermogard XP resulted in direct cost savings of £2339 and £2925 (per patient) compared with Blanketrol III and Arctic Sun 5000, respectively, and a gain of 0.98 QALYs over the patient lifetime. The probabilistic sensitivity analysis demonstrated that the probability of Thermogard XP being cost saving would be 69.2% and 65.3% versus the Arctic Sun 5000 and Blanketrol III, respectively. CONCLUSION Implementation of IVTM using Thermogard XP can lead to cost savings and improved patient quality of life versus surface cooling methods.
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Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, Southampton, UK
| | | | | | | | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon, UK
- MTRC, Anglia Ruskin School of Medicine, Chelmsford, UK
| | - Mohsen Yaghoubi
- Mercer University College of Pharmacy, 3001 Mercer University Dr, Atlanta, GA, 30341, USA.
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Ramadanov N, Arrich J, Klein R, Herkner H, Behringer W. Intravascular Versus Surface Cooling in Patients Resuscitated From Cardiac Arrest: A Systematic Review and Network Meta-Analysis With Focus on Temperature Feedback. Crit Care Med 2022; 50:999-1009. [PMID: 35089906 PMCID: PMC9112968 DOI: 10.1097/ccm.0000000000005463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to compare the effect of intravascular cooling (IC), surface cooling with temperature feedback (SCF), and surface cooling without temperature feedback (SCnoF) on neurologic outcome and survival in patients successfully resuscitated from cardiac arrest (CA) and treated with targeted temperature management (TTM) at 32-34°C. DATA SOURCES We performed a systematic review on Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, SCOPUS, CINAHL, Web of Science, and Clinical Trials up to June 30, 2021. STUDY SELECTION We included randomized and nonrandomized studies on IC, SCF, and SCnoF in adult humans resuscitated from CA undergoing TTM, reporting neurologic outcome or survival. DATA EXTRACTION We performed a network meta-analysis to assess the comparative effects of IC, SCF, and SCnoF. The overall effect between two cooling methods included the effect of direct and indirect comparisons. Results are given as odds ratios (OR) and 95% CIs. Rankograms estimated the probability of TTM methods being ranked first, second, and third best interventions. DATA SYNTHESIS A total of 14 studies involving 4,062 patients met the inclusion criteria. Four studies were randomized controlled studies, and 10 studies were nonrandomized observational studies. IC compared with SCnoF was significantly associated with better neurologic outcome (OR, 0.6; 95% CI, 0.49-0.74) and survival (OR, 0.8; 95% CI, 0.66-0.96). IC compared with SCF, and SCF compared with SCnoF did not show significant differences in neurologic outcome and survival. The rankogram showed that IC had the highest probability to be the most beneficial cooling method, followed by SCF and SCnoF. CONCLUSIONS Our results suggest that in patients resuscitated from CA and treated with TTM at 32-34°C, IC has the highest probability of being the most beneficial cooling method for survival and neurologic outcome.
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Affiliation(s)
- Nikolai Ramadanov
- Department of Emergency Medicine, Faculty of Medicine, Friedrich Schiller University, Jena, Germany
- Emergency Department, University Hospital Brandenburg, Brandenburg, Germany
| | - Jasmin Arrich
- Department of Emergency Medicine, Faculty of Medicine, Friedrich Schiller University, Jena, Germany
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Klein
- Department for Trauma Surgery and Spine Surgery, ViDia Christian Hospitals, Karlsruhe, Germany
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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Kim JG, Choi HY, Kang GH, Jang YS, Kim W, Lee Y. Prognostic value of targeted temperature management on outcomes of hanging-induced out-of-hospital cardiac arrest: A nationwide observational study. Medicine (Baltimore) 2022; 101:e28688. [PMID: 35119012 PMCID: PMC8812659 DOI: 10.1097/md.0000000000028688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 12/17/2021] [Accepted: 01/03/2022] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT This study aimed to evaluate the prognostic significance of targeted temperature management (TTM) on hanging-induced out-of-hospital cardiac arrest (OHCA) patients using nationwide data of South Korea.Adult hanging-induced OHCA patients from 2008 to 2018 were included in this nationwide observational study. Patients who assigned into 2 groups based on whether they did (TTM group) or did not (non-TTM group) receive TTM. Outcome measures included survival to hospital discharge and a good neurological outcome at hospital discharge.Among the 293,852 OHCA patients, 3545 patients (non-TTM, n = 2762; TTM, n = 783) were investigated. After propensity score matching for all patients, 783 matched pairs were available for analysis. We observed no significant inter-group differences in the survival to hospital discharge (non-TTM, n = 27 [3.4%] vs TTM, n = 23 [2.9%], P = .666) or good neurological outcomes (non-TTM, n = 23 [2.9%] vs TTM, n = 14 [1.8%], P = .183). In the multivariate analysis, prehospital return of spontaneous circulation (odds ratio [OR], 22.849; 95% confidence interval [CI], 11.479-45.481, P < .001) was associated with an increase in survival to hospital discharge, and age (OR, 0.971; 95% CI, 0.944-0.998, P = .035), heart disease (OR, 16.875; 95% CI, 3.028-94.036, P = .001), and prehospital return of spontaneous circulation (OR, 133.251; 95% CI, 30.512-581.930, P < .001) were significant prognostic factors of good neurological outcome. However, TTM showed no significant association with either outcome.There were no significant differences in the survival to hospital discharge and good neurological outcomes between non-TTM and TTM groups of hanging-induced OHCA patients.
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Herpertz GU, Nykamp L, Radke OC. [Lethal Heatstroke with Disseminated Intravascular Coagulopathy]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:68-78. [PMID: 35021241 DOI: 10.1055/a-1508-0726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We report on a case of severe heat stroke due to extended exposure to the sun in an enclosed glass cabin of an agricultural vehicle. Patient treatment, lab results and complications are reported and we examine the current literature on heat stroke.Heat stroke is a very rare and highly severe condition mostly suffered by vulnerable individuals or individuals exposed to extreme physical strain. Per definition a heat stroke is characterized by neurological deficit (especially loss of consciousness), and a high body temperature. Most important treatment is to lower the body temperature below 40 °C as quickly as possible. The best method is cold water immersion, but there are several other physical and invasive means that can be used. If performed within 30 minutes after the beginning of the incident this treatment decreases mortality considerably.Heat damage affects every organ and organ system. Most important are neurologic deficits, cardiovascular failure, liver failure and kidney failure. The excessive heat triggers a systemic inflammatory response syndrome (SIRS) which can lead to a disseminated intravascular coagulopathy (DIC). Haemostasis is also directly affected by the elevated temperature.Besides physical cooling, there is no known specific treatment to prevent secondary damage from heat stroke. Additionally, supportive care and ICU monitoring should be applied.
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Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, Okada N, Kitamura T, Ohta B. Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study. Ann Intensive Care 2021; 11:163. [PMID: 34825993 PMCID: PMC8626556 DOI: 10.1186/s13613-021-00953-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/15/2021] [Indexed: 01/27/2023] Open
Abstract
Background Little is known about the effectiveness of surface cooling (SC) and endovascular cooling (EC) on the outcome of out-of-hospital cardiac arrest (OHCA) patients receiving target temperature management (TTM) according to their initial rhythm. Methods We retrospectively analysed data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest registry, a multicentre, prospective nationwide database in Japan. For our analysis, OHCA patients aged ≥ 18 years who were treated with TTM between June 2014 and December 2017 were included. The primary outcome was 30-day survival with favourable neurological outcome defined as a Glasgow–Pittsburgh cerebral performance category score of 1 or 2. Cooling methods were divided into the following groups: SC (ice packs, fans, air blankets, and surface gel pads) and EC (endovascular catheters and any dialysis technique). We investigated the efficacy of the two categories of cooling methods in two different patient groups divided according to their initially documented rhythm at the scene (shockable or non-shockable) using multivariable logistic regression analysis and propensity score analysis with inverse probability weighting (IPW). Results In the final analysis, 1082 patients were included. Of these, 513 (47.4%) had an initial shockable rhythm and 569 (52.6%) had an initial non-shockable rhythm. The proportion of patients with favourable neurological outcomes in SC and EC was 59.9% vs. 58.3% (264/441 vs. 42/72), and 11.8% (58/490) vs. 21.5% (17/79) in the initial shockable patients and the initial non-shockable patients, respectively. In the multivariable logistic regression analysis, differences between the two cooling methods were not observed among the initial shockable patients (adjusted odd ratio [AOR] 1.51, 95% CI 0.76–3.03), while EC was associated with better neurological outcome among the initial non-shockable patients (AOR 2.21, 95% CI 1.19–4.11). This association was constant in propensity score analysis with IPW (OR 1.40, 95% CI 0.83–2.36; OR 1.87, 95% CI 1.01–3.47 among the initial shockable and non-shockable patients, respectively). Conclusion We suggested that the use of EC was associated with better neurological outcomes in OHCA patients with initial non-shockable rhythm, but not in those with initial shockable rhythm. A TTM implementation strategy based on initial rhythm may be important. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00953-y.
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Affiliation(s)
- Makoto Watanabe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Hikaru Oe
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Makoto Sasaki
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Nakamura
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, 602-8566, Japan
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Review of Hypothermia Protocol and Timing of the Echocardiogram. Curr Probl Cardiol 2021; 46:100786. [PMID: 33516091 DOI: 10.1016/j.cpcardiol.2021.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/24/2022]
Abstract
Targeted temperature management, also known as therapeutic hypothermia (TH), is recommended for out-of-hospital cardiac arrest (OHCA). Both internal or external methods of cooling can be applied. Individuals resuscitated from OHCA frequently develop postarrest myocardial dysfunction resulting in decreased cardiac output and left ventricular systolic function. This dysfunction is usually transient and improves with spontaneous recovery over time. Echocardiogram (ECHO) can be a vital tool for the assessment and management of these patients. This manuscript reviewed methods available for TH after OHCA and reviews role of ECHO in the diagnosis and prognosis in this setting.
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Garfield B, Abdoolraheem MY, Dixon A, Aswani A, Paul R, Sherren P, Glover G. Temporal Changes in Targeted Temperature Management for Out-of-Hospital Cardiac Arrest-Examining the Effect of the Targeted Temperature Management Trial: A Retrospective Cohort Study. Ther Hypothermia Temp Manag 2020; 11:230-237. [PMID: 33332235 DOI: 10.1089/ther.2020.0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Targeted temperature management (TTM) is recommended after out-of-hospital cardiac arrest (OHCA). However, interpretation of the evidence and translation into clinical practice, to realize benefits to patient outcomes may be inconsistent. This study aims to compare compliance with the recommended targeted temperatures and the use of intravascular temperature management (IVTM), as well as 90-day survival, before and after publication of the TTM trial. A single-center retrospective cohort study was conducted from 2010 to 2017. All comatose patients admitted to the intensive care unit after OHCA, who survived for ≥24 hours, were included. IVTM use was measured and TTM adherence was defined as the percentage time the core temperature was (1) within the guideline-recommended temperature range (initially 32-34°C, later modified to 32-36°C) for the first 24 hours, and (2) ≤37.5°C between 24 and 72 hours following admission. Multiple logistic regression analyses were performed for the use of IVTM and survival at 90 days. Of the 302 patients identified, 136 (45%) were pre-TTM, and 166 (55%) post-TTM. Baseline characteristics were similar between the groups. IVTM use decreased significantly (77.9% vs. 51.8%, p < 0.001) after the publication of the TTM trial. Adherence to the 32-34°C and 32-36°C targets was higher pre-TTM as compared with the post-TTM cohort (33.3% [0-66.7%] vs. 0% [0-16.7%], p < 0.001 and 83.3% [50.0-100%] vs. 36.7% [16.7-66.7%], p < 0.001, respectively). Time with temperature ≥37.5°C in the first 24 hours was higher post-TTM (p = < 0.001) but not between 24 and 72 hours. Ninety-day survival was 54.4% in the pre-TTM cohort and 44.0% post-TTM, (odds ratio 1.52 [0.96-2.40], p = 0.083). Adherence with recommended TTM decreased significantly following publication of the TTM trial and this was explained by a significant decrease in IVTM use. However, this concerning trend did not result in a statistically significant difference in survival.
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Affiliation(s)
- Benjamin Garfield
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
| | | | - Alison Dixon
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
| | - Andrew Aswani
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
| | - Richard Paul
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
| | - Peter Sherren
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
| | - Guy Glover
- Department of Critical Care, Guy's and St. Thomas', King's College London, London, United Kingdom
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Use of a Servo-Controlled Cooling Gel Pad System to Regulate Body Temperature in Critically Ill Children. Pediatr Crit Care Med 2020; 21:e1094-e1098. [PMID: 32769700 DOI: 10.1097/pcc.0000000000002563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of a servo-controlled cooling pad system for target temperature management in critically ill pediatric patients. DESIGN A prospective, single-center, observational study. SETTING PICU of a tertiary hospital from September 2018 to September 2019. PATIENTS Children from 28 days to 16 years old subjected to servo-controlled body temperature control. METHODS The Arctic Sun 5000 system (Bard Medical, Covington, GA) and Arctic Gel Hydrogel pads were used for the purposes of the study. Data collected included demographics, indication of therapy, patient's body temperature, target temperature, time-to-target temperature, duration of therapy, and need to start or increase sedation and/or muscle relaxants. MEASUREMENTS AND MAIN RESULTS A total of 16 patients were included, of whom 68.8% were male; mean age was 4.7 years. The most frequent indication was fever associated with hemodynamic instability (62.5%). The target temperature was normothermia (36 or 36.5°C) in 81% of cases. Mean baseline body temperature was 37.6°C (± 1.2°C), and 50% of patients had fever (> 38°C). The mean speed of cooling was 1.2°C/hr (± 1°C/hr). Mean time to target temperature was 118 minutes (± 98.8 min). Mean duration of therapy was 68.7 hours (± 58.3 hr). Two patients had fever related to device disconnection during the treatment. At the start of the therapy, 15 patients were receiving sedative and analgesic drugs, and four received muscle relaxants. A patient required increased sedation, whereas another patient needed to start muscle relaxants. One of the patients developed a skin lesion in the axilla, no other adverse events were registered. CONCLUSIONS Despite the small sample size, the results of the study showed that target temperature management by the servo-controlled gel pad system in critically ill pediatric patients was effective in achieving satisfactory temperature control and it was well-tolerated.
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Callaway CW, Coppler PJ, Faro J, Puyana JS, Solanki P, Dezfulian C, Doshi AA, Elmer J, Frisch A, Guyette FX, Okubo M, Rittenberger JC, Weissman A. Association of Initial Illness Severity and Outcomes After Cardiac Arrest With Targeted Temperature Management at 36 °C or 33 °C. JAMA Netw Open 2020; 3:e208215. [PMID: 32701158 PMCID: PMC7378753 DOI: 10.1001/jamanetworkopen.2020.8215] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest. OBJECTIVE To examine whether illness severity is associated with changes in the association between target temperature and patient outcome. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation. EXPOSURE TTM at 36 °C or 33 °C. MAIN OUTCOMES AND MEASURES Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category. RESULTS Among 1319 patients, 728 (55.2%) had TTM at 33 °C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36 °C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33 °C with TTM at 36 °C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference, -13.8%; 95% CI, -24.4% to -3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies. CONCLUSIONS AND RELEVANCE In this study, TTM at 33 °C was associated with better survival than TTM at 36 °C among patients with the most severe post-cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36 °C was associated with better survival among patients with mild- to moderate-severity illness.
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Affiliation(s)
- Clifton W. Callaway
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J. Coppler
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Faro
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob S. Puyana
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pawan Solanki
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cameron Dezfulian
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ankur A. Doshi
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Elmer
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam Frisch
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Francis X. Guyette
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Masashi Okubo
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jon C. Rittenberger
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alexandra Weissman
- Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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20
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Alcamo AM, Lavezoli R, Dezfulian C, Simon DW, Aneja RK, Clark RSB, Kochanek PM, Fink EL. Feasibility and Performance of a Gel-Adhesive Pad System for Pediatric Targeted Temperature Management: An Exploratory Analysis of 19 Pediatric Critically Ill Patients. Ther Hypothermia Temp Manag 2020; 11:19-27. [PMID: 32429750 DOI: 10.1089/ther.2020.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Targeted temperature management (TTM) is an important treatment modality in pediatric neurocritical care. There are different types of devices available to deliver this therapy, but limited pediatric data exist. This quality improvement study evaluates the use of a surface cooling device that uses gel-adhesive pads for TTM in critically ill pediatric patients. An institutional TTM protocol to use the gel-adhesive pad system was developed with three different temperature goals: normothermia (goal temperature 37°C), mild hypothermia (goal temperature 35°C with rewarming duration of 12 hours to normothermia), and moderate hypothermia (goal temperature 33°C with rewarming duration of 24 hours to normothermia). Protocol and device implementation required several different educational sessions for all members of the critical care team. An exploratory analysis was performed for 19 patients with complete clinical and device temperature data. The most common protocol used was normothermia (73.6%). By protocol, time to goal temperature was 58 minutes (22.0-112.8) for normothermia, 46.5 minutes (44.3-48.8) for mild hypothermia, and 93 minutes (46.5-406.5) for moderate hypothermia. Patients remained within ±0.5°C temperature goal 99% (96.0-99.3) of the time in the normothermia protocol, 99.5% (99-100) in mild hypothermia, and 93% (80-100) for the moderate hypothermia protocol. Shivering was the most common adverse event (35%). Our results show that use of the gel-adhesive pad system for pediatric TTM is feasible, efficacious with regard to achieving both a short time to target temperature and maintaining temperature goal, and, in this limited sample, was free from major adverse events. We also defined several technical aspects of device use in pediatric patients that should be considered in future trial design and/or clinical use. Further studies are needed to determine if this device is superior to other cooling devices for temperature management in the pediatric population.
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Affiliation(s)
- Alicia M Alcamo
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rebecca Lavezoli
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cameron Dezfulian
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dennis W Simon
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rajesh K Aneja
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S B Clark
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ericka L Fink
- Department of Critical Care Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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21
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Sonnier M, Rittenberger JC. State-of-the-art considerations in post-arrest care. J Am Coll Emerg Physicians Open 2020; 1:107-116. [PMID: 33000021 PMCID: PMC7493544 DOI: 10.1002/emp2.12022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Cardiac arrest has a high rate of morbidity and mortality. Several advances in post-cardiac arrest management can improve outcome, but are time-dependent, placing the emergency physician in a critical role to both recognize the need for and initiate therapy. We present a novel perspective of both the workup and therapeutic interventions geared toward the emergency physician during the first few hours of care. We describe how the immediate care of a post-cardiac arrest patient is resource intensive and requires simultaneous evaluation for the underlying cause and intensive management to prevent further end organ damage, particularly of the central nervous system. The goal of the initial focused assessment is to rapidly determine if any reversible causes of cardiac arrest are present and to intervene when possible. Interventions performed in this acute period are aimed at preventing additional brain injury through optimizing hemodynamics, providing ventilatory support, and by using therapeutic hypothermia when indicated. After the initial phase of care, disposition is guided by available resources and the clinician's judgment. Transfer to a specialized cardiac arrest center is prudent in centers that do not have significant support or experience in the care of these patients.
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Affiliation(s)
| | - Jon C. Rittenberger
- Guthrie Robert Packer HospitalSayrePennsylvania
- Geisinger Commonwealth Medical CollegeScrantonPennsylvania
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22
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Effect of therapy hypothermia on hemodynamic status of post cardiac arrest in acute myocardial infarction. ENFERMERIA CLINICA 2020. [DOI: 10.1016/j.enfcli.2019.12.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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23
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Kim JG, Ahn C, Shin H, Kim W, Lim TH, Jang BH, Cho Y, Choi KS, Lee J, Na MK. Efficacy of the cooling method for targeted temperature management in post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2020; 148:14-24. [DOI: 10.1016/j.resuscitation.2019.12.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
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24
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Liao X, Zhou Z, Zhou M, Tang H, Feng M, Kou B, Zhu N, Liao F, Wu L. Effects of endovascular and surface cooling on resuscitation in patients with cardiac arrest and a comparison of effectiveness, stability, and safety: a systematic review and meta-analysis. Crit Care 2020; 24:27. [PMID: 31992342 PMCID: PMC6988375 DOI: 10.1186/s13054-020-2731-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 01/10/2020] [Indexed: 12/11/2022] Open
Abstract
Objectives This study conducted a meta-analysis to assess the effectiveness, stability, and safety of mild therapeutic hypothermia (TH) induced by endovascular cooling (EC) and surface cooling (SC) and its effect on ICU, survival rate, and neurological function integrity in adult CA patients. Methods We developed inclusion criteria, intervention protocols, results, and data collection. The results included outcomes during target temperature management as well as ICU stay, survival rate, and neurological functional integrity. The characteristics of the included population and each study were analyzed. Results Four thousand nine hundred thirteen participants met the inclusion criteria. Those receiving EC had a better cooling efficiency (cooling rates MD = 0.31[0.13, 0.50], p < 0.01; induced cooling times MD = − 90.45[− 167.57, − 13.33], p = 0.02; patients achieving the target temperature RR = 1.60[1.19, 2.15], p < 0.01) and thermal stability during the maintenance phase (maintenance time MD = 2.35[1.22, 3.48], p < 0.01; temperature fluctuation MD = − 0.68[− 1.03, − 0.33], p < 0.01; overcooling RR = 0.33[0.23, 0.49], p < 0.01). There were no differences in ICU survival rate (RR = 1.22[0.98, 1.52], p = 0.07, I2 = 0%) and hospital survival rate (RR = 1.02 [0.96, 1.09], p = 0.46, I2 = 0%), but EC reduced the length of stay in ICU (MD = − 1.83[− 3.45, − 0.21], p = 0.03, I2 = 49%) and improved outcome of favorable neurological function at discharge (RR = 1.15[1.04, 1.28], p < 0.01, I2 = 0%). EC may delay the hypothermia initiation time, and there was no significant difference between the two cooling methods in the time from the start of patients’ cardiac arrest to achieve the target temperature (MD = − 46.64[− 175.86, 82.58]). EC was superior to non-ArcticSun in terms of cooling efficiency. Although there was no statistical difference in ICU survival rate, ICU length of stay, and hospitalization survival rate, in comparison to non-ArcticSun, EC improved rates of neurologically intact survival (RR = 1.16 [1.01, 1.35], p = 0.04, I2 = 0%). Conclusions Among adult patients receiving cardiopulmonary resuscitation, although there is no significant difference between the two cooling methods in the time from the start of cardiac arrest to achieve the target temperature, the faster cooling rate and more stable cooling process in EC shorten patients’ ICU hospitalization time and help more patients obtain good neurological prognosis compared with patients receiving SC. Meanwhile, although EC has no significant difference in patient outcomes compared with ArcticSun, EC has improved rates of neurologically intact survival.
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Affiliation(s)
- Xueli Liao
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Ziyu Zhou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Manhong Zhou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China.
| | - Hui Tang
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Menglong Feng
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Bujin Kou
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Ni Zhu
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Futuan Liao
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
| | - Liaozhang Wu
- The Emergency Department, The Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
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Bartlett ES, Valenzuela T, Idris A, Deye N, Glover G, Gillies MA, Taccone FS, Sunde K, Flint AC, Thiele H, Arrich J, Hemphill C, Holzer M, Skrifvars MB, Pittl U, Polderman KH, Ong MEH, Kim KH, Oh SH, Do Shin S, Kirkegaard H, Nichol G. Systematic review and meta-analysis of intravascular temperature management vs. surface cooling in comatose patients resuscitated from cardiac arrest. Resuscitation 2019; 146:82-95. [PMID: 31730898 DOI: 10.1016/j.resuscitation.2019.10.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To systematically review the effectiveness and safety of intravascular temperature management (IVTM) vs. surface cooling methods (SCM) for induced hypothermia (IH). METHODS Systematic review and meta-analysis. English-language PubMed, Embase and the Cochrane Database of Systematic Reviews were searched on May 27, 2019. The quality of included observational studies was graded using the Newcastle-Ottawa Quality Assessment tool. The quality of included randomized trials was evaluated using the Cochrane Collaboration's risk of bias tool. Random effects modeling was used to calculate risk differences for each outcome. Statistical heterogeneity and publication bias were assessed using standard methods. ELIGIBILITY Observational or randomized studies comparing survival and/or neurologic outcomes in adults aged 18 years or greater resuscitated from out-of-hospital cardiac arrest receiving IH via IVTM vs. SCM were eligible for inclusion. RESULTS In total, 12 studies met inclusion criteria. These enrolled 1573 patients who received IVTM; and 4008 who received SCM. Survival was 55.0% in the IVTM group and 51.2% in the SCM group [pooled risk difference 2% (95% CI -1%, 5%)]. Good neurological outcome was achieved in 40.9% in the IVTM and 29.5% in the surface group [pooled risk difference 5% (95% CI 2%, 8%)]. There was a 6% (95% CI 11%, 2%) lower risk of arrhythmia with use of IVTM and 15% (95% CI 22%, 7%) decreased risk of overcooling with use of IVTM vs. SCM. There was no significant difference in other evaluated adverse events between groups. CONCLUSIONS IVTM was associated with improved neurological outcomes vs. SCM among survivors resuscitated following cardiac arrest. These results may have implications for care of patients in the emergency department and intensive care settings after resuscitation from cardiac arrest.
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Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States.
| | - Terence Valenzuela
- Department of Emergency Medicine, University of Arizona, Tucson, AZ, United States; Tucson Fire Department, Tucson, AZ, United States
| | - Ahamed Idris
- Departments of Emergency and Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Nicolas Deye
- Medical Intensive Care Unit, Inserm U942, Lariboisiere Hospital, APHP, F-75010, Paris, France
| | - Guy Glover
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael A Gillies
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Fabio S Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Hopital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alexander C Flint
- Divison of Research, Kaiser Permanente, Oakland, CA, United States; Neuroscience Department, Kaiser Permanente, Redwood City, CA, United States
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jasmin Arrich
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria; Center of Emergency Medicine, University of Jena, Faculty of Medicine, Jena, Germany
| | - Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, United States
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Undine Pittl
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Kees H Polderman
- Essex Cardiothoracic Centre, Basildon, Essex, SS16 5NL, United Kingdom; Anglia Ruskin School of Medicine, Chelmsford, CM1 1SQ, United Kingdom; United General Hospital, Houston, TX, United States
| | - Marcus E H Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Graham Nichol
- Department of Emergency Medicine, University of Washington, Seattle, WA, United States; Department of Internal Medicine, University of Washington, Seattle, WA, United States; University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, WA, United States
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Abstract
Fever represents a frequent and dangerous secondary insult for the injured brain and is often associated with worsened neurological outcomes. The identification of fever in the Neuro-Intensive Care Unit requires careful monitoring and rapid and effective treatment. The main objective of this article was to provide practical information regarding temperature monitoring, triggers for intervention and fever management in brain injured patients.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy -
| | - Francesco Minardi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
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27
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Effect of different methods of cooling for targeted temperature management on outcome after cardiac arrest: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:285. [PMID: 31443696 PMCID: PMC6708171 DOI: 10.1186/s13054-019-2567-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/13/2019] [Indexed: 02/03/2023]
Abstract
Background Although targeted temperature management (TTM) is recommended in comatose survivors after cardiac arrest (CA), the optimal method to deliver TTM remains unknown. We performed a meta-analysis to evaluate the effects of different TTM methods on survival and neurological outcome after adult CA. Methods We searched on the MEDLINE/PubMed database until 22 February 2019 for comparative studies that evaluated at least two different TTM methods in CA patients. Data were extracted independently by two authors. We used the Newcastle-Ottawa Scale and a modified Cochrane ROB tools for assessing the risk of bias of each study. The primary outcome was the occurrence of unfavorable neurological outcome (UO); secondary outcomes included overall mortality. Results Our search identified 6886 studies; 22 studies (n = 8027 patients) were included in the final analysis. When compared to surface cooling, core methods showed a lower probability of UO (OR 0.85 [95% CIs 0.75–0.96]; p = 0.008) but not mortality (OR 0.88 [95% CIs 0.62–1.25]; p = 0.21). No significant heterogeneity was observed among studies. However, these effects were observed in the analyses of non-RCTs. A significant lower probability of both UO and mortality were observed when invasive TTM methods were compared to non-invasive TTM methods and when temperature feedback devices (TFD) were compared to non-TFD methods. These results were significant particularly in non-RCTs. Conclusions Although existing literature is mostly based on retrospective or prospective studies, specific TTM methods (i.e., core, invasive, and with TFD) were associated with a lower probability of poor neurological outcome when compared to other methods in adult CA survivors (CRD42019111021). Electronic supplementary material The online version of this article (10.1186/s13054-019-2567-6) contains supplementary material, which is available to authorized users.
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28
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A new paradigm for lung-conservative total liquid ventilation. EBioMedicine 2019; 52:102365. [PMID: 31447395 PMCID: PMC7033528 DOI: 10.1016/j.ebiom.2019.08.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/06/2019] [Accepted: 08/12/2019] [Indexed: 12/23/2022] Open
Abstract
Background Total liquid ventilation (TLV) of the lungs could provide radically new benefits in critically ill patients requiring lung lavage or ultra-fast cooling after cardiac arrest. It consists in an initial filling of the lungs with perfluorocarbons and subsequent tidal ventilation using a dedicated liquid ventilator. Here, we propose a new paradigm for a lung-conservative TLV using pulmonary volumes of perfluorocarbons below functional residual capacity (FRC). Methods and findings Using a dedicated technology, we showed that perfluorocarbon end-expiratory volumes could be maintained below expected FRC and lead to better respiratory recovery, preserved lung structure and accelerated evaporation of liquid residues as compared to complete lung filling in piglets. Such TLV below FRC prevented volutrauma through preservation of alveolar recruitment reserve. When used with temperature-controlled perfluorocarbons, this lung-conservative approach provided neuroprotective ultra-fast cooling in a model of hypoxic-ischemic encephalopathy. The scale-up and automating of the technology confirmed that incomplete initial lung filling during TLV was beneficial in human adult-sized pigs, despite larger size and maturity of the lungs. Our results were confirmed in aged non-human primates, confirming the safety of this lung-conservative approach. Interpretation This study demonstrated that TLV with an accurate control of perfluorocarbon volume below FRC could provide the full potential of TLV in an innovative and safe manner. This constitutes a new paradigm through the tidal liquid ventilation of incompletely filled lungs, which strongly differs from the previously known TLV approach, opening promising perspectives for a safer clinical translation. Fund ANR (COOLIVENT), FRM (DBS20140930781), SATT IdfInnov (project 273).
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Storm C, Behringer W, Wolfrum S, Michels G, Fink K, Kill C, Arrich J, Leithner C, Ploner C, Busch HJ. [Postcardiac arrest treatment guide]. Med Klin Intensivmed Notfmed 2019; 115:573-584. [PMID: 31197420 DOI: 10.1007/s00063-019-0591-6] [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: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome. AIM The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines. MATERIALS AND METHODS Attention was paid to a concise, practice-oriented presentation. RESULTS AND DISCUSSION The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.
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Affiliation(s)
- C Storm
- Medizinische Klinik mit Schwerpunkt Nephrologie und Internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland.
| | - W Behringer
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - S Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Lübeck, Lübeck, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - K Fink
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland
| | - C Kill
- Zentrum für Notfallmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - J Arrich
- Zentrum für Notfallmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - C Leithner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - C Ploner
- Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Sir-Hans-A.-Krebs-Straße, 79106, Freiburg Breisgau, Deutschland.
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Cooling via Trans-nasal High Flow Ambient Air: Does it Pass the Smell Test? Neurocrit Care 2019; 30:505-507. [PMID: 30903589 DOI: 10.1007/s12028-019-00701-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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31
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Schroeder DC, Maul AC, Guschlbauer M, Finke SR, de la Puente Bethencourt D, Neumann T, Padosch SA, Annecke T, Böttiger BW, Sterner-Kock A, Herff H. Esophageal Heat Exchanger Versus Water-Circulating Cooling Blanket for Targeted Temperature Management. Ther Hypothermia Temp Manag 2019; 9:251-257. [PMID: 30893023 DOI: 10.1089/ther.2018.0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To date, the optimal cooling device for targeted temperature management (TTM) remains unclear. Water-circulating cooling blankets are broadly available and quickly applied but reveal inaccuracy during maintenance and rewarming period. Recently, esophageal heat exchangers (EHEs) have been shown to be easily inserted, revealed effective cooling rates (0.26-1.12°C/h), acceptable deviations from target core temperature (<0.5°C), and rewarming rates between 0.2 and 0.4°C/h. The aim of this study was to compare cooling rates, accuracy during maintenance, and rewarming period as well as side effects of EHEs with water-circulating cooling blankets in a porcine TTM model. Mean core temperature of domestic pigs (n = 16) weighing 83.2 ± 3.6 kg was decreased to a target core temperature of 33°C by either using EHEs or water-circulating cooling blankets. After 8 hours of maintenance, rewarming was started at a goal rate of 0.25°C/h. Mean cooling rates were 1.3 ± 0.1°C/h (EHE) and 3.2 ± 0.5°C/h (blanket, p < 0.0002). Mean difference to target core temperature during maintenance ranged between ±1°C. Mean rewarming rates were 0.21 ± 0.01°C/h (EHE) and 0.22 ± 0.02°C/h (blanket, n.s.). There were no differences with regard to side effects such as brady- or tachycardia, hypo- or hyperkalemia, hypo- or hyperglycemia, hypotension, shivering, or esophageal tissue damage. Target temperature can be achieved faster by water-circulating cooling blankets. EHEs and water-circulating cooling blankets were demonstrated to be reliable and safe cooling devices in a prolonged porcine TTM model with more variability in EHE group.
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Affiliation(s)
- Daniel C Schroeder
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alexandra C Maul
- Department of Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Maria Guschlbauer
- Department of Experimental Medicine, University Hospital of Cologne, Cologne, Germany.,Decentral Animal Facility, University Hospital of Cologne, Cologne, Germany
| | - Simon-Richard Finke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Tobias Neumann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Stephan A Padosch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Annecke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anja Sterner-Kock
- Department of Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Holger Herff
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
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Intravascular versus surface cooling for targeted temperature management after out-of-hospital cardiac arrest: an analysis of the TTH48 trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:61. [PMID: 30795782 PMCID: PMC6385423 DOI: 10.1186/s13054-019-2335-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
Abstract
Background The aim of this study was to explore the performance and outcomes for intravascular (IC) versus surface cooling devices (SFC) for targeted temperature management (TTM) after out-of-hospital cardiac arrest. Methods A retrospective analysis of data from the Time-differentiated Therapeutic Hypothermia (TTH48) trial (NCT01689077), which compared whether TTM at 33 °C for 48 h results in better neurologic outcomes compared with standard 24-h duration. Devices were assessed for the speed of cooling and rewarming rates. Precision was assessed by measuring temperature variability (TV), i.e., the standard deviation (SD) of all temperature measurements in the cooling phase. Main outcomes were overall mortality and poor neurological outcome, including death, severe disability, or vegetative status. Results A total of 352 patients had available data and were included in the analysis; of those, 218 (62%) were managed with IC. A total of 114/218 (53%) patients with IC and 61/134 (43%) with SFC were cooled for 48 h (p = 0.22). Time to target temperature (≤ 34 °C) was significantly shorter for patients treated with endovascular devices (2.2 [1.1–4.0] vs. 4.2 [2.7–6.0] h, p < 0.001), but temperature was also lower on admission (35.0 [34.2–35.6] vs. 35.3 [34.5–35.8]°C; p = 0.02) and cooling rate was similar (0.4 [0.2–0.8] vs. 0.4 [0.2–0.6]°C/h; p = 0.14) when compared to SFC. Temperature variability was significantly lower in the endovascular device group when compared with SFC methods (0.6 [0.4–0.9] vs. 0.7 [0.5–1.0]°C; p = 0.007), as was rewarming rate (0.31 [0.22–0.44] vs. 0.37 [0.29–0.49]°C/hour; p = 0.02). There was no statistically significant difference in mortality (endovascular 65/218, 29% vs. others 43/134, 32%; p = 0.72) or poor neurological outcome (endovascular 69/218, 32% vs. others 51/134, 38%; p = 0.24) between type of devices. Conclusions Endovascular cooling devices were more precise than SFC methods in patients cooled at 33 °C after out-of-hospital cardiac arrest. Main outcomes were similar with regard to the cooling methods.
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Nichol G, Polderman KH, Friberg H, Kurz M, Kapinos G. Perspectives on Temperature Management. Ther Hypothermia Temp Manag 2018; 8:188-194. [DOI: 10.1089/ther.2018.29052.gjn] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Division of Internal Medicine, Seattle, Washington
| | - Kees H. Polderman
- The Essex Cardiothoracic Centre, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Hans Friberg
- Department of Emergency Medicine, Skane University Hospital, Lund University, Lund, Sweden
| | - Michael Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gregory Kapinos
- Departments of Neurology, Neurosurgery and Emergency Medicine, Kings County Hospital/SUNY Downstate College of Medicine, Brooklyn, New York
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Lundbye J, Greer DM, Polderman KH, Yokobori S. Temperature Management in Neurological and Neurosurgical Intensive Care Unit. Ther Hypothermia Temp Manag 2018; 8:66-69. [PMID: 29742005 DOI: 10.1089/ther.2018.29044.jjl] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Justin Lundbye
- 1 The Greater Waterbury Health Network , Waterbury, Connecticut
| | - David M Greer
- 2 Department of Neurology, Yale University , New Haven, Connecticut
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Shoji Yokobori
- 4 Department of Emergency and Critical Care Medicine, Nippon Medical School , Tokyo, Japan
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