1
|
You Y, Gong Z, Zhang Y, Qiu L, Tang X. Observation of the effect of hypothermia therapy combined with optimized nursing on brain protection after cardiopulmonary resuscitation: A retrospective case-control study. Medicine (Baltimore) 2024; 103:e37776. [PMID: 38640316 PMCID: PMC11029950 DOI: 10.1097/md.0000000000037776] [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] [Received: 08/26/2023] [Revised: 12/20/2023] [Accepted: 03/12/2024] [Indexed: 04/21/2024] Open
Abstract
This study aimed to investigate the impact of optimized emergency nursing in conjunction with mild hypothermia nursing on neurological prognosis, hemodynamics, and complications in patients with cardiac arrest. A retrospective analysis was conducted on the medical records of 124 patients who received successful cardiopulmonary resuscitation (CPR) at Fujian Provincial Hospital South Branch. The patients were divided into control and observation groups, each consisting of 62 cases. The brain function of both groups was assessed using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale. Additionally, serum neuron-specific enolase level was measured in both groups. The vital signs and hemodynamics of both groups were analyzed, and the complications and satisfaction experienced by the 2 groups were compared. The experimental group exhibited significantly improved neurological function than the control group (P < .05). Furthermore, the heart rate in the experimental group was significantly lower than the control group (P < .05). However, no significant differences were observed in blood oxygen saturation, mean arterial pressure, central venous pressure, and systolic blood pressure between the 2 groups (P > 0.05). Moreover, the implementation of optimized nursing practices significantly reduced complications and improved the quality of life and satisfaction of post-CPR patients (P < .05). The integration of optimized emergency nursing practices in conjunction with CPR improves neurological outcomes in patients with cardiac arrest.
Collapse
Affiliation(s)
- Yan You
- The Second Department of Intensive Care Unit, Fujian Provincial Hospital South Branch, Fuzhou, China
| | - Zheng Gong
- Department of Emergency Medicine, Fujian Provincial Hospital, Fuzhou, China
- Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Fujian Provincial Key Laboratory of Emergency Medicine, Fuzhou, China
| | - Yaxu Zhang
- The Second Department of Intensive Care Unit, Fujian Provincial Hospital South Branch, Fuzhou, China
| | - Lirong Qiu
- The Second Department of Intensive Care Unit, Fujian Provincial Hospital South Branch, Fuzhou, China
| | - Xiahong Tang
- Department of Critical Care Medicine, The Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| |
Collapse
|
2
|
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
|
3
|
Strålin A, Thuccani M, Lilja L, Rylander C. Targeted temperature management evolving over time ‐ a local process analysis. Acta Anaesthesiol Scand 2022; 66:1116-1123. [PMID: 36106859 PMCID: PMC9540125 DOI: 10.1111/aas.14125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Axel Strålin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Meena Thuccani
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg Sahlgrenska University Hospital Gothenburg Sweden
| |
Collapse
|
4
|
Chen S, Lachance BB, Gao L, Jia X. Targeted temperature management and early neuro-prognostication after cardiac arrest. J Cereb Blood Flow Metab 2021; 41:1193-1209. [PMID: 33444088 PMCID: PMC8142127 DOI: 10.1177/0271678x20970059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Targeted temperature management (TTM) is a recommended neuroprotective intervention for coma after out-of-hospital cardiac arrest (OHCA). However, controversies exist concerning the proper implementation and overall efficacy of post-CA TTM, particularly related to optimal timing and depth of TTM and cooling methods. A review of the literature finds that optimizing and individualizing TTM remains an open question requiring further clinical investigation. This paper will summarize the preclinical and clinical trial data to-date, current recommendations, and future directions of this therapy, including new cooling methods under investigation. For now, early induction, maintenance for at least 24 hours, and slow rewarming utilizing endovascular methods may be preferred. Moreover, timely and accurate neuro-prognostication is valuable for guiding ethical and cost-effective management of post-CA coma. Current evidence for early neuro-prognostication after TTM suggests that a combination of initial prediction models, biomarkers, neuroimaging, and electrophysiological methods is the optimal strategy in predicting neurological functional outcomes.
Collapse
Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
5
|
Alshami A, Einav S, Skrifvars MB, Varon J. Administration of inhaled noble and other gases after cardiopulmonary resuscitation: A systematic review. Am J Emerg Med 2020; 38:2179-2184. [PMID: 33071073 DOI: 10.1016/j.ajem.2020.06.066] [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] [Received: 04/08/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Inhalation of noble and other gases after cardiac arrest (CA) might improve neurological and cardiac outcomes. This article discusses up-to-date information on this novel therapeutic intervention. DATA SOURCES CENTRAL, MEDLINE, online published abstracts from conference proceedings, clinical trial registry clinicaltrials.gov, and reference lists of relevant papers were systematically searched from January 1960 till March 2019. STUDY SELECTION Preclinical and clinical studies, irrespective of their types or described outcomes, were included. DATA EXTRACTION Abstract screening, study selection, and data extraction were performed by two independent authors. Due to the paucity of human trials, risk of bias assessment was not performed DATA SYNTHESIS: After screening 281 interventional studies, we included an overall of 27. Only, xenon, helium, hydrogen, and nitric oxide have been or are being studied on humans. Xenon, nitric oxide, and hydrogen show both neuroprotective and cardiotonic features, while argon and hydrogen sulfide seem neuroprotective, but not cardiotonic. Most gases have elicited neurohistological protection in preclinical studies; however, only hydrogen and hydrogen sulfide appeared to preserve CA1 sector of hippocampus, the most vulnerable area in the brain for hypoxia. CONCLUSION Inhalation of certain gases after CPR appears promising in mitigating neurological and cardiac damage and may become the next successful neuroprotective and cardiotonic interventions.
Collapse
Affiliation(s)
- Abbas Alshami
- Jersey Shore University Medical Center, Neptune, NJ, USA; Dorrington Medical Associates, PA, Houston, TX, USA
| | - Sharon Einav
- Intensive Care Unit of the Share Zedek Medical Center and Faculty of Medicine of the Hebrew University, Jerusalem, Israel
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Joseph Varon
- The University of Texas Health Science Center at Houston, USA; University of Texas Medical Branch at Galveston, USA; United Memorial Medical Center/United General Hospital, Houston, TX, USA.
| |
Collapse
|
6
|
Boulé-Laghzali N, Pérez LD, Dyrda K, Tanguay JF, Chabot-Blanchet M, Lamarche Y, Parent D, Dupriez AF, Deschamps A, Ducharme A. Targeted Temperature Management After Cardiac Arrest: The Montreal Heart Institute Experience. CJC Open 2020; 1:238-244. [PMID: 32159115 PMCID: PMC7063633 DOI: 10.1016/j.cjco.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/10/2019] [Indexed: 11/02/2022] Open
Abstract
Background Targeted temperature management (TTM) has been associated with an improvement in neurological function and survival in patients with cardiac arrest (CA) and an initially shockable rhythm. We report the Montreal Heart Institute (MHI) experience using TTM to evaluate mortality and neurological outcome in patients remaining in coma after CA, regardless of the initial rhythm. Methods We performed a retrospective review of all patients receiving TTM at the MHI between 2008 and 2015. Primary outcome was a composite of mortality and poor neurological outcome at hospital discharge. We also evaluated the long-term outcomes of those who initially survived to hospital discharge. Results A total of 147 patients (120 men, mean age 59.5 ± 12.5 years) underwent TTM at the MHI during the study period. Overall survival to hospital discharge with good neurological outcome was 45.6%. Shockable rhythm was associated with a better outcome (mortality odds ratio, 0.212; 95% confidence interval, 0.068-0.664; P = 0.008). Of the 11 initial survivors with a poor neurological status (Cerebral Performance Category ≥ 3), 4 died rapidly (within 1 month of hospital discharge), but 6 (54.5%) markedly improved their neurological status to Cerebral Performance Category 1. Long-term survival (mean follow-up of 38 ± 26 months) for those alive at hospital discharge (n = 76 patients) was 81.9%. Conclusion Our retrospective analysis of CA survivors treated with TTM at MHI showed good survival, similar to the published results from the landmark randomized controlled trials, despite enrolling patients with nonshockable rhythms. A significant proportion of survivors with poor neurological outcome at discharge improved at follow-up.
Collapse
Affiliation(s)
- Nadia Boulé-Laghzali
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Laura Dominguez Pérez
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Jean-François Tanguay
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | | | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Daniel Parent
- Department of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Anne-Frédérique Dupriez
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| |
Collapse
|
7
|
Polderman KH, Varon J. Targeted temperature management after cardiac arrest: And the optimal target is….? Resuscitation 2019; 146:263-265. [PMID: 31816336 DOI: 10.1016/j.resuscitation.2019.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/28/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Kees H Polderman
- Department of Intensive Care, The Essex Cardiothoracic Centre, Basildon University Hospital, United Kingdom; Department of Critical Care Medicine, United General Hospital, Houston, TX 77054, United States; The University of Texas Health Science Center at Houston, United Memorial Medical Center, Houston, TX United States.
| | - Joseph Varon
- Department of Critical Care Medicine, United General Hospital, Houston, TX 77054, United States; The University of Texas Health Science Center at Houston, United Memorial Medical Center, Houston, TX United States.
| |
Collapse
|
8
|
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
|
9
|
Okazaki T, Hifumi T, Kawakita K, Kuroda Y. Targeted temperature management guided by the severity of hyperlactatemia for out-of-hospital cardiac arrest patients: a post hoc analysis of a nationwide, multicenter prospective registry. Ann Intensive Care 2019; 9:127. [PMID: 31745738 PMCID: PMC6864017 DOI: 10.1186/s13613-019-0603-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background The International Liaison Committee on Resuscitation guidelines recommend target temperature management (TTM) between 32 and 36 °C for patients after out-of-hospital cardiac arrest, but did not indicate patient-specific temperatures. The association of serum lactate concentration and neurological outcome in out-of-hospital cardiac arrest patient has been reported. The study aim was to investigate the benefit of 32–34 °C in patients with various degrees of hyperlactatemia compared to 35–36 °C. Methods This study was a post hoc analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry between June 2014 and December 2015. Patients with complete targeted temperature management and lactate data were eligible. Patients were stratified to mild (< 7 mmol/l), moderate (< 12 mmol/l), or severe (≥ 12 mmol/l) hyperlactatemia group based on lactate concentration after return of spontaneous circulation. They were subdivided into 32–34 °C or 35–36 °C groups. The primary endpoint was an adjusted predicted probability of 30-day favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. Result Of 435 patients, 139 had mild, 182 had moderate, and 114 had severe hyperlactatemia. One hundred and eight (78%) with mild, 128 with moderate (70%), and 83 with severe hyperlactatemia (73%) received TTM at 32–34 °C. The adjusted predicted probability of a 30-day favorable neurological outcome following severe hyperlactatemia was significantly greater with 32–34 °C (27.4%, 95% confidence interval: 22.0–32.8%) than 35–36 °C (12.4%, 95% CI 3.5–21.2%; p = 0.005). The differences in outcomes in those with mild and moderate hyperlactatemia were not significant. Conclusions In OHCA patients with severe hyperlactatemia, the adjusted predicted probability of 30-day favorable neurological outcome was greater with TTM at 32–34 °C than with TTM at 35–36 °C. Further evaluation is needed to determine whether TTM at 32–34 °C can improve neurological outcomes in patients with severe hyperlactatemia after out-of-hospital cardiac arrest.
Collapse
Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan.
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Kita, Miki, Kagawa, 761-0793, Japan
| | | |
Collapse
|
10
|
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).
Collapse
|
11
|
|
12
|
Polderman K, Lundbye J, Nichol G, Le May M. Therapeutic Hypothermia in Postcardiac Arrest. Ther Hypothermia Temp Manag 2019; 9:102-107. [PMID: 31120398 DOI: 10.1089/ther.2019.29060.khp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Kees Polderman
- 1 Department of Intensive Care Basildon and Thurrock University Hospitals, Anglia Ruskin School of Medicine, London-Essex, United Kingdom
| | - Justin Lundbye
- 2 The Greater Waterbury Health Network, Waterbury, Connecticut
| | - Graham Nichol
- 3 University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, Washington
| | - Michel Le May
- 4 Division of Cardiac Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| |
Collapse
|
13
|
Polderman KH, Varon J. Confusion Around Therapeutic Temperature Management Hypothermia After In-Hospital Cardiac Arrest? Circulation 2019; 137:219-221. [PMID: 29335283 DOI: 10.1161/circulationaha.117.029656] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, PA (K.H.P.)
| | - Joseph Varon
- University of Texas Health Science Center at Houston (J.V.).,University of Texas Medical Branch at Galveston, Foundation Surgical Hospital of Houston (J.V.)
| |
Collapse
|
14
|
Lundbye J, Lyden PD, Polderman KH, Schwab S. Clinical Studies Targeting Stroke and Ischemic Insults. Ther Hypothermia Temp Manag 2018; 7:12-15. [PMID: 28253089 DOI: 10.1089/ther.2016.29022.jjl] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Justin Lundbye
- 1 Hospital of Central Connecticut , New Britain, Connecticut
| | - Patrick D Lyden
- 2 Department of Neurology, Cedars-Medical Center , Los Angeles, California
| | - Kees H Polderman
- 3 Department of Critical Care, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Stefan Schwab
- 4 Department of Neurology, Friedrich-Alexander University , Erlangen, Germany
| |
Collapse
|
15
|
Chava R, Zviman M, Assis FR, Raghavan MS, Halperin H, Maqbool F, Geocadin R, Quinones-Hinojosa A, Kolandaivelu A, Rosen BA, Tandri H. Effect of high flow transnasal dry air on core body temperature in intubated human subjects. Resuscitation 2018; 134:49-54. [PMID: 30359664 DOI: 10.1016/j.resuscitation.2018.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/08/2018] [Accepted: 10/15/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Early initiation of hypothermia is recommended in the setting of cardiac arrest. Current hypothermia methods are invasive and expensive and not applicable in ambulatory settings. We investigated the evaporative cooling effect of high flow transnasal dry air on core esophageal temperature in human volunteers. METHODS & RESULTS A total of 32 subjects (mean age 53.2 ± 9.3 yrs., mean weight 90 ± 17 kg) presenting for elective electrophysiological procedures were enrolled for the study. Half of the subjects were men. Following general anesthesia induction, high flow (30 LPM) medical grade ambient dry air with a relative humidity ∼20% was administered through a nasal mask for 60 min. Core temperature was monitored at the distal esophagus. Half of the subjects (16/32) were subject to high flow air and the remainder served as controls. Over a 1-h period, mean esophageal temperature decreased from 36.1 ± 0.3 °C to 35.5 ± 0.1 °C in the test subjects (p < 0.05). No significant change in temperature was observed in the control subjects (36.3 ± 0.3 °C to 36.2 ± 0.2 °C, p = NS). No adverse events occurred. CONCLUSION Transnasal high flow dry air through the nasopharynx reduces core body temperature. This mechanism can be harnessed to induce hypothermia in patients where clinically indicated without any deleteriouseffects in a short time exposure.
Collapse
Affiliation(s)
- Raghuram Chava
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Menekhem Zviman
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabrizio R Assis
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Henry Halperin
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Farhan Maqbool
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko Geocadin
- Department of Neuroanesthesia and Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alfredo Quinones-Hinojosa
- Department of Neuroanesthesia and Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aravindan Kolandaivelu
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin A Rosen
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
16
|
Affiliation(s)
- Kees H Polderman
- Department of Critical Care Medicine, United General Hospital, Houston, TX 77054, USA.,Department of Intensive Care, Basildon University Hospital, Basildon, UK
| |
Collapse
|
17
|
Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
Collapse
|
18
|
Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
Collapse
Affiliation(s)
- Fred Rincon
- Division of Critical Care and Neurotrauma, Department of Neurology, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA; Division of Critical Care and Neurotrauma, Department of Neurological Surgery, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
| |
Collapse
|
19
|
Abstract
Cardiac arrest is the most common cause of death in North America. An organized bundle of neurocritical care interventions can improve chances of survival and neurological recovery in patients who are successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an Emergency Neurological Life Support protocol. Key aspects of successful early post-arrest management include: prevention of secondary brain injury; identification of treatable causes of arrest in need of emergent intervention; and, delayed neurological prognostication. Secondary brain injury can be attenuated through targeted temperature management (TTM), avoidance of hypoxia and hypotension, avoidance of hyperoxia, hyperventilation or hypoventilation, and treatment of seizures. Most patients remaining comatose after resuscitation from cardiac arrest should undergo TTM. Treatable precipitants of arrest that require emergent intervention include, but are not limited to, acute coronary syndrome, intracranial hemorrhage, pulmonary embolism and major trauma. Accurate neurological prognostication is generally not appropriate for several days after cardiac arrest, so early aggressive care should never be limited based on perceived poor neurological prognosis.
Collapse
Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
20
|
Alshami A, Varon J. How long should we wait for patients to wake up when they undergo targeted temperature management? Resuscitation 2018; 126:A1-A2. [PMID: 29476893 DOI: 10.1016/j.resuscitation.2018.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - Joseph Varon
- United Memorial Medical Centre, Houston, TX, USA; The University of Texas Health Science, Center at Houston, Houston, TX, USA; The University of Texas Medical Branch at Galveston, Houston, TX, USA.
| |
Collapse
|
21
|
Polderman K, Malinoski D, Timerman S, Keeble T. Current Advances in the Use of Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2018; 8:9-13. [PMID: 29356614 DOI: 10.1089/ther.2017.29040.khp] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Kees Polderman
- 1 Department of Critical Care, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Darren Malinoski
- 2 Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Sergio Timerman
- 3 Medicine and Health Sciences, Laureate International Universities , Sao Paulo, Brazil
| | - Thomas Keeble
- 4 Essex Cardiothoracic Centre, Anglia Ruskin University , Cambridge, United Kingdom
| |
Collapse
|
22
|
Sonder P, Janssens GN, Beishuizen A, Henry CL, Rittenberger JC, Callaway CW, Dezfulian C, Polderman KH. Efficacy of different cooling technologies for therapeutic temperature management: A prospective intervention study. Resuscitation 2017; 124:14-20. [PMID: 29288014 DOI: 10.1016/j.resuscitation.2017.12.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/13/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Mild therapeutic hypothermia (32-36 °C) is associated with improved outcomes in patients with brain injury after cardiac arrest (CA). Various devices are available to induce and maintain hypothermia, but few studies have compared the performance of these devices. We performed a prospective study to compare four frequently used cooling systems in inducing and maintaining hypothermia followed by controlled rewarming. METHODS We performed a prospective multi-centered study in ten ICU's in three hospitals within the UPMC health system. Four different cooling technologies (seven cooling methods in total) were studied: two external water-circulating cooling blankets (Meditherm® and Blanketrol®), gel-coated adhesive cooling pads (Arctic Sun®), and endovascular cooling catheters with balloons circulating ice-cold saline (Thermogard®). For the latter system we studied three different types of catheter with two, three or four water-circulating balloons, respectively. In contrast to previous studies, we not only studied the cooling rate (i.e., time to target temperature) in the induction phase, but also the percentage of the time during the maintenance phase that temperature was on target ±0.5 °C, and the efficacy of devices to control rewarming. We believe that these are more important indicators of device performance than induction speed alone. RESULTS 129 consecutive patients admitted after CA and treated with hypothermia were screened, and 120 were enrolled in the study. Two researchers dedicated fulltime to this study monitored TH treatment in all patients, including antishivering measures, additional cooling measures used (e.g. icepacks and cold fluid infusion), and all other issues related to temperature management. Baseline characteristics were similar for all groups. Cooling rates were 2.06 ± 1.12 °C/h for endovascular cooling, 1.49 ± 0.82 for Arctic sun, 0.61 ± 0.36 for Meditherm and 1.22 ± 1.12 for Blanketrol. Time within target range ±0.5 °C was 97.3 ± 6.0% for Thermogard, 81.8 ± 25.2% for Arctic Sun, 57.4 ± 29.3% for Meditherm, and 64.5 ± 20.1% for Blanketrol. The following differences were significant: Thermogard vs. Meditherm (p < 0.01), Thermogard vs. Blanketrol (p < 0.01), and Arctic Sun vs. Meditherm (p < 0.02). No major complications occurred with any device. CONCLUSIONS Endovascular cooling and gel-adhesive pads provide more rapid hypothermia induction and more effective temperature maintenance compared to water-circulating cooling blankets. This applied to induction speed, but (more importantly) also to time within target range during maintenance.
Collapse
Affiliation(s)
- Petra Sonder
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213, United States
| | - Gladys N Janssens
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213, United States
| | - Albertus Beishuizen
- Department of Critical Care Medicine, VU University Medical Center, PO Box 7075, 1007 MB Amsterdam, The Netherlands; Department of Critical Care Medicine, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ Enschede, The Netherlands
| | - Connie L Henry
- UPMC Mercy Hospital, University of Pittsburgh School of Medicine, 1400 Locust St, Pittsburgh, PA 15219, United States
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh Medical Center, 3600 Forbes Avenue, Suite 400A, Pittsburgh, PA 15261, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh Medical Center, 3600 Forbes Avenue, Suite 400A, Pittsburgh, PA 15261, United States
| | - Cameron Dezfulian
- Department of Emergency Medicine, University of Pittsburgh Medical Center, 3600 Forbes Avenue, Suite 400A, Pittsburgh, PA 15261, United States
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213, United States.
| |
Collapse
|
23
|
Rittenberger J, Kurz M, Polderman KH. Therapeutic Hypothermia in Postcardiac Arrest. Ther Hypothermia Temp Manag 2017; 7:184-187. [PMID: 29027885 DOI: 10.1089/ther.2017.29036.jjr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jon Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Michael Kurz
- 2 Department of Emergency Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| |
Collapse
|
24
|
Riley RM, Varon J. Neurological outcome after cardiac arrest managed with targeted temperature management: Are hemodynamic variables useful? Resuscitation 2017; 120:A11-A12. [PMID: 28830715 DOI: 10.1016/j.resuscitation.2017.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Rachel M Riley
- Dorrington Medical Associates, PA United Memorial Medical Center Houston, TX, USA; Associate Professor of Medicine, Universidad Anahuac Campus Cancun-Mexico
| | - Joseph Varon
- United Memorial Medical Center, The University of Texas Health Science Center at Houston, USA; The University of Texas Medical Branch at Galveston, 2219 Dorrington Street, Houston, TX, USA.
| |
Collapse
|
25
|
Riley RM, Varon J. When and how to freeze: It is all about SPAME! Resuscitation 2017; 116:A1-A2. [DOI: 10.1016/j.resuscitation.2017.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
|
26
|
Pearson DA, Mayer K, Wares CM, Runyon MS, Studnek JR, Ward SL, Kraft KM, Heffner AC. Factors Associated with Delayed Cooling in Cardiac Arrest Patients. Ther Hypothermia Temp Manag 2017; 7:81-87. [PMID: 28418788 DOI: 10.1089/ther.2016.0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Therapeutic hypothermia has been shown to improve neurologic outcome in medical cardiac arrest patients, yet little is known about factors that delay target temperature achievement. Our primary aim was to identify factors associated with not achieving our institutional "door-to-cool" (DTC) performance goal (emergency department [ED] arrival to temperature of 34°C) of ≤4 hours. Secondary aims included whether achievement of DTC goal was associated with timing of bolus neuromuscular blockade (NMB), survival, or functional outcome. This was a retrospective cohort study of a medical cardiac arrest quality improvement (QI) database that included patients treated from November 2007 to August 2012. The database was queried for patient demographics, arrest characteristics, specific cooling techniques used, whether patients underwent emergent computed tomography imaging or cardiac catheterization, and patient outcomes. Logistic regression was used to assess the factors associated with DTC goal performance and outcomes. We enrolled 327 patients, median age 58, median return of spontaneous circulation (ROSC) time of 21 minutes (interquartile range [IQR] 14-29 minutes), and shockable initial rhythm in 61%. One hundred forty-four (44%) patients survived to hospital discharge, 133 (41%) with good functional outcome, as defined as cerebral performance category 1-2. Induction with cold IV fluids [OR 0.50 (CI: 0.29-0.85)] and NMB administration within 2 hours of ED arrival [OR 2.95 (CI: 1.17-7.43)] was associated with achieving DTC goal. Logistic regression showed that achievement of DTC goal ≤4 hours [OR 0.59 (0.32-1.09)] was not associated with good functional outcome. In our single-center cohort, initiation of cold intravenous fluids (IVF) and early NMB administration were associated with improved DTC goal performance of 4 hours. However, patients achieving DTC goals were not associated with improved outcomes.
Collapse
Affiliation(s)
- David A Pearson
- 1 Department of Emergency Medicine, Carolinas Medical Center , Charlotte, North Carolina
| | | | - Catherine M Wares
- 1 Department of Emergency Medicine, Carolinas Medical Center , Charlotte, North Carolina
| | - Michael S Runyon
- 1 Department of Emergency Medicine, Carolinas Medical Center , Charlotte, North Carolina
| | | | - Shana L Ward
- 4 Carolinas Health Care System , Dickson Advanced Analytics Group, Charlotte, North Carolina
| | - Kathi M Kraft
- 4 Carolinas Health Care System , Dickson Advanced Analytics Group, Charlotte, North Carolina
| | - Alan C Heffner
- 1 Department of Emergency Medicine, Carolinas Medical Center , Charlotte, North Carolina.,5 Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center , Charlotte, North Carolina
| |
Collapse
|
27
|
Jentzer JC, Clements CM, Murphy JG, Scott Wright R. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care 2017; 39:97-107. [PMID: 28242531 DOI: 10.1016/j.jcrc.2017.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/18/2017] [Accepted: 02/01/2017] [Indexed: 01/31/2023]
Abstract
Cardiac arrest is the leading cause of death in Europe and the United States. Many patients who are initially resuscitated die in the hospital, and hospital survivors often have substantial neurologic dysfunction. Most cardiac arrests are caused by coronary artery disease; patients with coronary artery disease likely benefit from early coronary angiography and intervention. After resuscitation, cardiac arrest patients remain critically ill and frequently suffer cardiogenic shock and multiorgan failure. Early cardiopulmonary stabilization is important to prevent worsening organ injury. To achieve best patient outcomes, comprehensive critical care management is needed, with primary goals of stabilizing hemodynamics and preventing progressive brain injury. Targeted temperature management is frequently recommended for comatose survivors of cardiac arrest to mitigate the neurologic injury that drives outcomes. Accurate neurologic assessment is central to managing care of cardiac arrest survivors and should combine physical examination with objective neurologic testing, with the caveat that delaying neurologic prognosis is essential to avoid premature withdrawal of supportive care. A combination of clinical findings and diagnostic results should be used to estimate the likelihood of functional recovery. This review focuses on recent advances in care and specific cardiac intensive care strategies that may improve morbidity and mortality for patients after cardiac arrest.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | | | - Joseph G Murphy
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| |
Collapse
|
28
|
Lundbye J, Lyden PD, Polderman KH, Schwab S. Clinical Studies Targeting Stroke and Ischemic Insults. Ther Hypothermia Temp Manag 2017:ther.2016.29022.jjl.rev. [PMID: 28106522 DOI: 10.1089/ther.2016.29022.jjl.rev] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Justin Lundbye
- 1 The Greater Waterbury Health Network, Waterbury, Connecticut
| | - Patrick D Lyden
- 2 Department of Neurology, Cedars-Medical Center , Los Angeles, California
| | - Kees H Polderman
- 3 Department of Critical Care, University of Pittsburgh Medical Center , Pittsburgh, Pennsylvania
| | - Stefan Schwab
- 4 Department of Neurology, Friedrich-Alexander University , Erlangen, Germany
| |
Collapse
|
29
|
Wang CH, Huang CH, Chang WT, Tsai MS, Yu PH, Wu YW, Chen WJ. Outcomes of Adult In-Hospital Cardiac Arrest Treated with Targeted Temperature Management: A Retrospective Cohort Study. PLoS One 2016; 11:e0166148. [PMID: 27820847 PMCID: PMC5098791 DOI: 10.1371/journal.pone.0166148] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 10/24/2016] [Indexed: 11/27/2022] Open
Abstract
Aim Targeted temperature management (TTM) for in-hospital cardiac arrest (IHCA) is given different recommendation levels within international resuscitation guidelines. We aimed to identify whether TTM would be associated with favourable outcomes following IHCA and to determine which factors would influence the decision to implement TTM. Methods We conducted a retrospective observational study in a single medical centre. We included adult patients suffering IHCA between 2006 and 2014. We used multivariable logistic regression analysis to evaluate associations between independent variables and outcomes. Results We included a total of 678 patients in our analysis; only 22 (3.2%) patients received TTM. Most (81.1%) patients met at least one exclusion criteria for TTM. In all, 144 (21.2%) patients survived to hospital discharge; among them, 60 (8.8%) patients displayed favourable neurological status at discharge. TTM use was significantly associated with favourable neurological outcome (OR: 3.74, 95% confidence interval [CI]: 1.19–11.00; p-value = 0.02), but it was not associated with survival (OR: 1.41, 95% CI: 0.54–3.66; p-value = 0.48). Arrest in the emergency department was positively associated with TTM use (OR: 22.48, 95% CI: 8.40–67.64; p value < 0.001) and having vasopressors in place at the time of arrest was inversely associated with TTM use (OR: 0.08, 95% CI: 0.004–0.42; p-value = 0.02). Conclusion TTM might be associated with favourable neurological outcome of IHCA patients, irrespective of arrest rhythms. The prevalence of proposed exclusion criteria for TTM was high among IHCA patients, but these factors did not influence the use of TTM in clinical practice or neurological outcomes after IHCA.
Collapse
Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Yen-Wen Wu
- Departments of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nuclear Medicine and Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Emergency Medicine, Lotung Poh-Ai Hospital, Yilan, Taiwan
- * E-mail:
| |
Collapse
|
30
|
Schock RB, Janata A, Peacock WF, Deal NS, Kalra S, Sterz F. Time to Cooling Is Associated with Resuscitation Outcomes. Ther Hypothermia Temp Manag 2016; 6:208-217. [PMID: 27906641 PMCID: PMC5144870 DOI: 10.1089/ther.2016.0026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Our purpose was to analyze evidence related to timing of cooling from studies of targeted temperature management (TTM) after return of spontaneous circulation (ROSC) after cardiac arrest and to recommend directions for future therapy optimization. We conducted a preliminary review of studies of both animals and patients treated with post-ROSC TTM and hypothesized that a more rapid cooling strategy in the absence of volume-adding cold infusions would provide improved outcomes in comparison with slower cooling. We defined rapid cooling as the achievement of 34°C within 3.5 hours of ROSC without the use of volume-adding cold infusions, with a ≥3.0°C/hour rate of cooling. Using the PubMed database and a previously published systematic review, we identified clinical studies published from 2002 through 2014 related to TTM. Analysis included studies with time from collapse to ROSC of 20–30 minutes, reporting of time from ROSC to target temperature and rate of patients in ventricular tachycardia or ventricular fibrillation, and hypothermia maintained for 20–24 hours. The use of cardiopulmonary bypass as a cooling method was an exclusion criterion for this analysis. We compared all rapid cooling studies with all slower cooling studies of ≥100 patients. Eleven studies were initially identified for analysis, comprising 4091 patients. Two additional studies totaling 609 patients were added based on availability of unpublished data, bringing the total to 13 studies of 4700 patients. Outcomes for patients, dichotomized into faster and slower cooling approaches, were determined using weighted linear regression using IBM SPSS Statistics software. Rapid cooling without volume-adding cold infusions yielded a higher rate of good neurological recovery than slower cooling methods. Attainment of a temperature below 34°C within 3.5 hours of ROSC and using a cooling rate of more than 3°C/hour appear to be beneficial.
Collapse
Affiliation(s)
- Robert B Schock
- 1 Sid Wolvek Research Center , Life Recovery Systems HD, LLC, Kinnelon, New Jersey
| | - Andreas Janata
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
| | - W Frank Peacock
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | - Nathan S Deal
- 3 Emergency Medicine, Ben Taub General Hospital , Houston, Texas
| | | | - Fritz Sterz
- 2 Universitätsklinik für Notfallmedizin, Medizinische Universität Wien , Wien, Austria
| |
Collapse
|
31
|
Surani S, Varon J. The expanded use of targeted temperature management: Time for reappraisal. Resuscitation 2016; 108:A8-A9. [PMID: 27618758 DOI: 10.1016/j.resuscitation.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 09/04/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Salim Surani
- Texas A&M University, USA; University of North Texas, USA
| | - Joseph Varon
- The University of Texas Health Science Center at Houston, USA; The University of Texas Medical Branch at Galveston, USA; Foundation Surgical Hospital, Houston, TX, USA.
| |
Collapse
|
32
|
Rittenberger JC, Friess S, Polderman KH. Emergency Neurological Life Support: Resuscitation Following Cardiac Arrest. Neurocrit Care 2016; 23 Suppl 2:S119-28. [PMID: 26438463 DOI: 10.1007/s12028-015-0171-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac arrest is the most common cause of death in North America. Neurocritical care interventions, including targeted temperature management (TTM), have significantly improved neurological outcomes in patients successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an emergency neurological life support protocol. Patients remaining comatose following resuscitation from cardiac arrest should be considered for TTM. This protocol will review induction, maintenance, and re-warming phases of TTM, along with management of TTM side effects. Aggressive shivering suppression is necessary with this treatment to ensure the maintenance of a target temperature. Ancillary testing, including electrocardiography, computed tomography and/or magnetic resonance imaging of the brain, continuous electroencephalography monitoring, and correction of electrolyte, blood gas, and hematocrit changes, are also necessary to optimize outcomes.
Collapse
Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Stuart Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
33
|
Casamento A, Minson A, Radford S, Mårtensson J, Ridgeon E, Young P, Bellomo R. A comparison of therapeutic hypothermia and strict therapeutic normothermia after cardiac arrest. Resuscitation 2016; 106:83-8. [DOI: 10.1016/j.resuscitation.2016.06.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/15/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
|
34
|
Kim T, Paine MG, Meng H, Xiaodan R, Cohen J, Jinka T, Zheng H, Cranford JA, Neumar RW. Combined intra- and post-cardiac arrest hypothermic-targeted temperature management in a rat model of asphyxial cardiac arrest improves survival and neurologic outcome compared to either strategy alone. Resuscitation 2016; 107:94-101. [PMID: 27521473 DOI: 10.1016/j.resuscitation.2016.07.232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 06/29/2016] [Accepted: 07/15/2016] [Indexed: 10/21/2022]
Abstract
AIM Post-cardiac arrest hypothermic-targeted temperature management (HTTM) improves outcomes in preclinical cardiac arrest studies. However, inadequate understanding of the mechanisms and therapeutic windows remains a barrier to optimization. We tested the hypothesis that combined intra- and post-cardiac arrest HTTM provides a synergistic outcome benefit compared to either strategy alone. METHODS Rats subjected to 8-min asphyxial cardiac arrest were block randomized to 4 treatment groups (n=12/group): NTTM) normothermic-targeted temperature management; 1-24 HTTM) HTTM initiated 1h post-ROSC and maintained for 24h; Intra-1 HTTM) HTTM initiated at CPR onset and maintained for 1h; and Intra-24 HTTM) HTTM initiated at CPR onset and maintained for 24h. HTTM was induced by nasopharyngeal cooling and maintained using an automated temperature regulation system. Target temperature range was 36.5-37.5°C for NTTM and 32.0-34.0°C for HTTM. Post-arrest neurologic function score (NFS) was measured daily, and rats surviving 72h were euthanized for histological analysis of neurodegeneration. RESULTS Target brain temperature was achieved 7.8±3.3min after initiating intra-arrest cooling. The survival rate was 42%, 50%, 50%, and 92% in the NTTM, 1-24 HTTM, Intra-1 HTTM, and Intra-24 HTTM groups, respectively (p<0.05, Intra-24 group vs. all other groups). The rate of survival with good neurologic function (NFS≥450) was 33% in the Intra-24 HTTM group vs. 0% in all other groups (mid p<0.05). Hippocampal CA1 sector neurodegeneration was significantly reduced in the Intra-24 HTTM group compared to all other groups (p<0.05). CONCLUSION Combined intra- and post-cardiac arrest HTTM has greater outcome benefits than either strategy alone.
Collapse
Affiliation(s)
- Taeyun Kim
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Emergency Medicine, Gyeongsang National University Hospital, Republic of Korea
| | - Michael G Paine
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - He Meng
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Ren Xiaodan
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Jacob Cohen
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Tulasi Jinka
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States
| | - Huiyong Zheng
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Robert W Neumar
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, United States.
| |
Collapse
|
35
|
Casamento A, Bellomo R, Young P. Reply to Letter: Could one degree in temperature change the world? Maybe for targeted temperature management! Resuscitation 2016; 107:e13. [PMID: 27496261 DOI: 10.1016/j.resuscitation.2016.07.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew Casamento
- Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia; Intensive Care Unit, The Northern Hospital, Melbourne, Victoria, Australia.
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Melbourne, Victoria, Australia; School of Medicine, The University of Melbourne, Victoria, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| |
Collapse
|
36
|
Coppler PJ, Sawyer KN, Youn CS, Choi SP, Park KN, Kim YM, Reynolds JC, Gaieski DF, Lee BK, Oh JS, Kim WY, Moon HJ, Abella BS, Elmer J, Callaway CW, Rittenberger JC. Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators. Ther Hypothermia Temp Manag 2016; 7:30-35. [PMID: 27419613 DOI: 10.1089/ther.2016.0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.
Collapse
Affiliation(s)
- Patrick J Coppler
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Department of Physician Assistant Studies, University of the Sciences , Philadelphia, Pennsylvania
| | - Kelly N Sawyer
- 3 Department of Emergency Medicine, William Beaumont Hospital , Royal Oak, Michigan
| | - Chun Song Youn
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Seung Pill Choi
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Kyu Nam Park
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Young-Min Kim
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Joshua C Reynolds
- 5 Department of Emergency Medicine, Michigan State University College of Human Medicine , Grand Rapids, Michigan
| | - David F Gaieski
- 6 Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Hospital , Philadelphia, Pennsylvania
| | - Byung Kook Lee
- 7 Chonnam National University Hospital , Gwangju, South Korea
| | - Joo Suk Oh
- 4 Department of Emergency Medicine, The Catholic University of Korea , Seoul, South Korea
| | - Won Young Kim
- 8 Ulsan University College of Medicine , Asan Medical Center, Seoul, South Korea
| | - Hyung Jun Moon
- 9 Soonchunhyang University Cheonan Hospital , Cheonan, South Korea
| | - Benjamin S Abella
- 10 Department of Emergency Medicine, Pereleman School of Medicine at the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Jonathan Elmer
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,11 Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Clifton W Callaway
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Jon C Rittenberger
- 1 Department of Emergency Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| |
Collapse
|
37
|
|
38
|
Abstract
This update comprises six important topics under neurocritical care that require reevaluation. For post-cardiac arrest brain injury, the evaluation of the injury and its corresponding therapy, including temperature modulation, is required. Analgosedation for target temperature management is an essential strategy to prevent shivering and minimizes endogenous stress induced by catecholamine surges. For severe traumatic brain injury, the diverse effects of therapeutic hypothermia depend on the complicated pathophysiology of the condition. Continuous electroencephalogram monitoring is an essential tool for detecting nonconvulsive status epilepticus in the intensive care unit (ICU). Neurocritical care, including advanced hemodynamic monitoring, is a fundamental approach for delayed cerebral ischemia following subarachnoid hemorrhage. We must be mindful of the high percentage of ICU patients who may develop sepsis-associated brain dysfunction.
Collapse
Affiliation(s)
- Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa Japan 761-0793
| |
Collapse
|
39
|
Guschlbauer M, Maul AC, Yan X, Herff H, Annecke T, Sterner-Kock A, Böttiger BW, Schroeder DC. Zero-Heat-Flux Thermometry for Non-Invasive Measurement of Core Body Temperature in Pigs. PLoS One 2016; 11:e0150759. [PMID: 26938613 PMCID: PMC4777531 DOI: 10.1371/journal.pone.0150759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/18/2016] [Indexed: 11/29/2022] Open
Abstract
Hypothermia is a severe, unpleasant side effect during general anesthesia. Thus, temperature surveillance is a prerequisite in general anesthesia settings during experimental surgeries. The gold standard to measure the core body temperature (Tcore) is placement of a Swan-Ganz catheter in the pulmonary artery, which is a highly invasive procedure. Therefore, Tcore is commonly examined in the urine bladder and rectum. However, these procedures are known for their inaccuracy and delayed record of temperatures. Zero-heat-flux (ZHF) thermometry is an alternative, non-invasive method quantifying Tcore in human patients by applying a thermosensoric patch to the lateral forehead. Since the porcine cranial anatomy is different to the human’s, the optimal location of the patch remains unclear to date. The aim was to compare three different patch locations of ZHF thermometry in a porcine hypothermia model. Hypothermia (33.0°C Tcore) was conducted in 11 anesthetized female pigs (26-30kg). Tcore was measured continuously by an invasive Swan-Ganz catheter in the pulmonary artery (Tpulm). A ZHF thermometry device was mounted on three different defined locations. The smallest average difference between Tpulm and TZHF during stable temperatures was 0.21 ± 0.16°C at location A, where the patch was placed directly behind the eye. Also during rapidly changing temperatures location A showed the smallest bias with 0.48 ± 0.29°C. Location A provided the most reliable data for Tcore. Therefore, the ZHF thermometry patch should be placed directly behind the left temporal corner of the eye to provide a non-invasive method for accurate measurement of Tcore in pigs.
Collapse
Affiliation(s)
- Maria Guschlbauer
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alexandra C. Maul
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany
- * E-mail:
| | - Xiaowei Yan
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Holger Herff
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Annecke
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anja Sterner-Kock
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Daniel C. Schroeder
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| |
Collapse
|
40
|
Abstract
OPINION STATEMENT Resuscitated cardiac arrest continues to carry a poor prognosis despite advances in medical care. One such advance, therapeutic hypothermia, is neuroprotective and has been demonstrated to improve clinical outcomes in patients who remain unresponsive despite return of spontaneous circulation after arrhythmogenic cardiac arrest. Two landmark randomized controlled trials, both reported in 2002, led to endorsements by major American and European guidelines for therapeutic hypothermia as a viable treatment option for the prevention of adverse outcomes related to anoxic encephalopathy. Since then, significant research has been conducted to better understand the optimum strategies to maximize the neuroprotective effects of hypothermia. However, dissemination of therapeutic hypothermia guideline recommendations into clinical practice has been slow and incomplete. In this review article, we discuss the historical background and physiologic rationale for therapeutic hypothermia, review the recent literature supporting this intervention, and outline practical considerations.
Collapse
|
41
|
Chandrasekaran PN, Dezfulian C, Polderman KH. What is the right temperature to cool post-cardiac arrest patients? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:406. [PMID: 26577919 PMCID: PMC4650897 DOI: 10.1186/s13054-015-1134-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Citation Niklas Nielsen, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H. Targeted temperature management at 33 °C versus 36 °C after cardiac arrest. N Engl J Med. 2013;369:2197–206. doi:10.1056/NEJMoa1310519. Epub 2013 Nov 17. Pub Med PMID: 20089970. Background Brain ischemia and reperfusion injury leading to tissue degeneration and loss of neurological function following return of spontaneous circulation after cardiac arrest (CA) is a well-known entity. Two landmark trials in 2002 showed improved survival and neurological outcome of comatose survivors of out-of-hospital cardiac arrest (OHCA) of presumed cardiac origin when the patients were subjected to therapeutic hypothermia of 32 to 34 °C for 12 to 24 hours. However, the optimal target temperature for these cohorts is yet to be established and also it is not clear whether strict fever management and maintaining near normal body temperature are alone sufficient to improve the outcome. Methods Objective: The objective is to determine whether a hypothermic goal of a near-normal body temperature of 36 °C reduces all-cause mortality compared with a moderate hypothermia of 33 °C for the unconscious survivors of OHCA of presumed cardiac origin when subjected randomly to these different targeted temperatures. Design: A multicenter, international, open label, randomized controlled trial. Setting: Thirty-six ICUs in Europe and Australia participated in this study. Participants: Unconscious adults (older than 18 years of age) who survived (Glasgow coma scale less than 8) OHCA due to presumed cardiac origin with subsequent persistent return of spontaneous circulation (more than 20 minutes without chest compressions). Intervention: The above participant cohorts were randomized to targeted body temperature of either 33 °C or 36 °C for 36 hours after the CA with gradual rewarming of both groups to 37 °C (hourly increments of 0.5 °C) after the initial 28 hours. Body temperatures in both the groups were then maintained below 37.5 °C for 72 hours after the initial 36 hours. Outcomes: Primary outcome measure of all-cause mortality in both the groups at the end of the trial with the secondary outcome measure of all-cause mortality, composite neurological function as evaluated by cerebral performance category scale and modified ranking scale at the end of 180 days were studied. Results Out of the 939 participants, all-cause mortality at the end of the trial was 50 % in the 33 °C group (225 of 466 patients) compared with 48 % in the 36 °C group (235 of 473 patients); the hazard ratio with a temperature of 33 °C was 1.06 (95 % confidence interval (CI) 0.89 to 1.28, P = 0.51). At the end of 180 days, 54 % of patients in the 33 °C group versus 52 % in the 36 °C group had died or had poor neurological outcome according to cerebral performance category (risk ratio 1.02, 95 % CI 0.88 to 1.16, P = 0.78) but the modified ranking scale at the end of 180 days was unchanged (52 %) in both groups (risk ratio 1.01, 95 % CI 0.89 to 1.14, P = 0.87). Conclusions Maintaining targeted lower normothermia of 36 °C had similar outcomes compared with induced moderate hypothermia of 33 °C for unconscious survivors of OHCA of presumed cardiac cause.
Collapse
Affiliation(s)
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| |
Collapse
|
42
|
Islam S, Hampton-Till J, Watson N, Mannakkara NN, Hamarneh A, Webber T, Magee N, Abbey L, Jagathesan R, Kabir A, Sayer J, Robinson N, Aggarwal R, Clesham G, Kelly P, Gamma R, Tang K, Davies JR, Keeble TR. Early targeted brain COOLing in the cardiac CATHeterisation laboratory following cardiac arrest (COOLCATH). Resuscitation 2015; 97:61-7. [PMID: 26410565 DOI: 10.1016/j.resuscitation.2015.09.386] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/11/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory. METHODS 70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge. RESULTS There was no difference in time to reach ≤34 °C between Rhinochill and Blanketrol (Tympanic ≤34 °C, 75 vs. 107 mins; p=0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 °C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%. CONCLUSION In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.
Collapse
Affiliation(s)
- Shahed Islam
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - James Hampton-Till
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK
| | - Noel Watson
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | | | - Ashraf Hamarneh
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Teresa Webber
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Neil Magee
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Lucy Abbey
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Rohan Jagathesan
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Alamgir Kabir
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Jeremy Sayer
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Nicholas Robinson
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Rajesh Aggarwal
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Gerald Clesham
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Paul Kelly
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Reto Gamma
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - Kare Tang
- The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK
| | - John R Davies
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK.
| | - Thomas R Keeble
- Post Graduate Medical Institute (PMI), Anglia Ruskin University, Chelmsford, UK; The Essex Cardiothoracic Centre (CTC), Basildon, Essex, SS16 5NL, UK.
| |
Collapse
|
43
|
Abella BS, Varon J, Föedisch M, Tisherman S. Cooling Strategies Outside the Central Nervous System. Ther Hypothermia Temp Manag 2015; 5:116-20. [PMID: 26230299 DOI: 10.1089/ther.2015.29000.bsa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Joseph Varon
- 2 University of Texas Health Science Center , Houston, Texas
| | - Markus Föedisch
- 3 Department of Anesthesiology, Waldkrankenhaus Bonn-Bad Godesberg , Bonn, Germany
| | | |
Collapse
|
44
|
Polderman KH, Varon J. Interpreting the results of the targeted temperature management trial in cardiac arrest. Ther Hypothermia Temp Manag 2015; 5:73-6. [PMID: 25775183 DOI: 10.1089/ther.2014.0031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The targeted temperature management (TTM) trial, which found that cooling to 33°C after witnessed cardiac arrest (CA) conferred no benefits compared with 36°C, has led to much debate in the hypothermia community. This article discusses what lessons can be drawn. The TTM trial achieved far better outcomes in controls than any previous randomized controlled trial (RCT) or any nonrandomized study where no fever control was applied. On the other hand, rates of good outcomes in the hypothermia group were somewhat lower than in previous RCTs and most nonrandomized studies. The TTM authors conclude that benefits of temperature management are derived exclusively from fever control and that further lowering of temperature confers no benefit. Indeed, without doubt, the TTM trial demonstrates the crucial importance of strict fever control after CA and that this provides sufficient neuroprotection for some patients. However, we argue that the hypothermia intervention was executed suboptimally (possibly inadvertent selection bias; late start of cooling, up to 4 hours after ROSC; slow cooling rates, 10 hours to target temperature; more rapid rewarming than previous studies; and some other issues). This could explain high rates of good outcomes in controls and lower-than-expected rates in patients cooled to 33°C compared with previous randomized and nonrandomized studies. Outside of two previous RCTs, the use of hypothermia after CA is supported by hundreds of animal experiments, evidence from 46 before-after studies and large registries, and indirect supporting evidence from 7 RCTs in newborns with neonatal asphyxia. In addition, one RCT found improved outcomes with 32°C compared with 34°C. It remains to be explained why the TTM results so completely contradict previous studies in this field. These issues should be thoroughly discussed before changes in guidelines and protocols are made. Ending or modifying hypothermia treatment after CA should require the strongest possible evidence.
Collapse
Affiliation(s)
- Kees H Polderman
- 1 The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Joseph Varon
- 2 Department of Acute and Continuing Care, The University of Texas Health Science Center at Houston , Houston, Texas.,3 Department of Medicine, The University of Texas Medical Branch at Galveston , Galveston, Texas.,4 Department of Critical Care Services, University General Hospital , Houston, Texas
| |
Collapse
|