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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.
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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.
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2
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Nielsen N, Kirkegaard H. Rewarming: The neglected phase of targeted temperature management. Resuscitation 2020; 146:249-250. [PMID: 31655094 DOI: 10.1016/j.resuscitation.2019.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Helsingborg, Sweden.
| | - Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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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.
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Johnsson J, Wahlström J, Dankiewicz J, Annborn M, Agarwal S, Dupont A, Forsberg S, Friberg H, Hand R, Hirsch KG, May T, McPherson JA, Mooney MR, Patel N, Riker RR, Stammet P, Søreide E, Seder DB, Nielsen N. Functional outcomes associated with varying levels of targeted temperature management after out-of-hospital cardiac arrest - An INTCAR2 registry analysis. Resuscitation 2019; 146:229-236. [PMID: 31706964 DOI: 10.1016/j.resuscitation.2019.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/21/2019] [Accepted: 10/24/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been recommended in international guidelines since 2005. The TTM-trial published in 2013 showed no difference in survival or neurological outcome for patients randomised to 33 °C or 36 °C, and many hospitals have changed practice. The optimal utilization of TTM is still debated. This study aimed to analyse if a difference in temperature goal was associated with outcome in an unselected international registry population. METHODS This is a retrospective observational study based on a prospective registry - the International Cardiac Arrest Registry 2. Patients were categorized as receiving TTM in the lower range at 32-34 °C (TTM-low) or at 35-37 °C (TTM-high). Primary outcome was good functional status defined as cerebral performance category (CPC) of 1-2 at hospital discharge and secondary outcome was adverse events related to TTM. A logistic regression model was created to evaluate the independent effect of temperature by correcting for clinical and demographic factors associated with outcome. RESULTS Of 1710 patients included, 1242 (72,6%) received TTM-low and 468 (27,4%) TTM-high. In patients receiving TTM-low, 31.3% survived with good outcome compared to 28.8% in the TTM-high group. There was no significant association between temperature and outcome (p = 0.352). In analyses adjusted for baseline differences the OR for a good outcome with TTM-low was 1.27, 95% CI (0.94-1.73). Haemodynamic instability leading to discontinuation of TTM was more common in TTM-low. CONCLUSIONS No significant difference in functional outcome at hospital discharge was found in patients receiving lower- versus higher targeted temperature management.
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Affiliation(s)
- Jesper Johnsson
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden.
| | | | - Josef Dankiewicz
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Martin Annborn
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York City, United States
| | - Allison Dupont
- Department of Cardiology, Eastern Georgia, United States
| | - Sune Forsberg
- Department of Intensive Care, Norrtälje Hospital, Center for Resuscitation Science, Karolinska Institute, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Lund University, Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Robert Hand
- Department of Medical Services, Eastern Maine Medical Center, United States
| | - Karen G Hirsch
- Department of Neurology, Stanford University, United States
| | - Teresa May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | | | - Michael R Mooney
- Minneapolis Heart Institute, Abbott North-Western Hospital, United States
| | - Nainesh Patel
- Department of Cardiology, Lehigh Valley Health Network, PA, United States
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - David B Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - Niklas Nielsen
- Department of Anaesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden
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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.
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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
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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.
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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.
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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.
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8
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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.
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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]
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10
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Mayer SA, Fischer M, Polderman KH, Atkins C. Intraoperative Temperature Management. Ther Hypothermia Temp Manag 2017; 7:66-69. [PMID: 28561599 DOI: 10.1089/ther.2017.29030.sjm] [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)
- Stephan A Mayer
- 1 Department of Neurology, Henry Ford Health System , Detroit, Michigan
| | - Marlene Fischer
- 2 Klinik und Poiklinik fur Anasthesiologie, Universitatsklinikum Hamburg-Eppendorf , Hamburg Germany
| | - Kees H Polderman
- 3 Department of Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Coleen Atkins
- 4 Department of Neurological Surgery, University of Miami Miller School of Medicine , Miami, Florida
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11
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Kapinos G, Becker LB. The American Academy of Neurology affirms the revival of cooling for the revived. Neurology 2017; 88:2076-2077. [DOI: 10.1212/wnl.0000000000003968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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12
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Chavez LO, Leon M, Einav S, Varon J. Editor's Choice- Inside the cold heart: A review of therapeutic hypothermia cardioprotection. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:130-141. [PMID: 26714973 DOI: 10.1177/2048872615624242] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Targeted temperature management has been originally used to reduce neurological injury and improve outcome in patients after out-of-hospital cardiac arrest. Myocardial infarction remains a major cause of death in the world and several investigators are studying the effect of mild therapeutic hypothermia during an acute cardiac ischemic injury. A search on MEDLINE, Scopus and EMBASE databases was conducted to obtain data regarding the cardioprotective properties of therapeutic hypothermia. Preclinical studies have shown that therapeutic hypothermia provides a cardioprotective effect in animals. The proposed pathways for the cardioprotective effects of therapeutic hypothermia include stabilization of mitochondrial permeability, production of nitric oxide, equilibration of reactive oxygen species, and calcium channels homeostasis. Clinical trials in humans have yielded controversial results. Current trials are therefore seeking to combine therapeutic hypothermia with other treatment modalities in order to improve the outcomes of patients with acute ischemic injury. This article provides a review of the hypothermia effects on the cardiovascular system, from the basic science of physiological changes in the human body and molecular mechanisms of cardioprotection to the bench of clinical trials with therapeutic hypothermia in patients with acute ischemic injury.
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Affiliation(s)
- Luis O Chavez
- 1 University General Hospital, Houston, USA.,2 Universidad Autonoma de Baja California, Facultad de Medicina y Psicología, Tijuana, Mexico
| | - Monica Leon
- 1 University General Hospital, Houston, USA.,3 Universidad Popular Autonoma del Estado de Puebla, Facultad de Medicina Puebla, Mexico
| | - Sharon Einav
- 4 Shaare Zedek Medical Center and Hadassah-Hebrew University Faculty of Medicine, Jerusalem, Israel
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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.
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14
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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.
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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
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15
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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]
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Leary M, Blewer AL, Delfin G, Abella BS. Variability in Postarrest Targeted Temperature Management Practice: Implications of the 2015 Guidelines. Ther Hypothermia Temp Manag 2015; 5:184-7. [PMID: 26642933 PMCID: PMC4677534 DOI: 10.1089/ther.2015.0027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
In 2002 postarrest care was significantly altered when multiple randomized controlled trials found that therapeutic hypothermia at a goal temperature of 32-34°C significantly improved survival and neurologic outcomes. In 2013, targeted temperature management (TTM) was reexamined via a randomized controlled trial between 33°C and 36°C in post-cardiac arrest patients and found similar outcomes in both cohorts. Before the release of the 2015 American Heart Association (AHA) Guidelines, our group found that across hospitals in the United States, and even within the same institution, TTM protocol variability existed. After the 2013 TTM trial, it was anticipated that the 2015 Guidelines would clarify which target temperature should be used during postarrest care. The AHA released their updates for post-cardiac arrest TTM recently and, based on the literature available, have recommended the use of TTM at a goal temperature between 32°C and 36°C. Whether this variability has an effect on TTM implementation or patient outcomes is unknown.
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Affiliation(s)
- Marion Leary
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 2 School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Audrey L Blewer
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 3 Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Gail Delfin
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Benjamin S Abella
- 1 Department of Emergency Medicine, Center for Resuscitation Science, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
- 4 Section of Pulmonary Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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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.
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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.
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Polderman K, Nielsen N, Graffagnino C, Wayne M. Therapeutic hypothermia in post-cardiac arrest. Ther Hypothermia Temp Manag 2015; 4:154-8. [PMID: 25402717 DOI: 10.1089/ther.2014.1515] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kees Polderman
- 1 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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Affiliation(s)
- Kees H Polderman
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (K.H.P.); University of Pittsburgh Medical Center, Pittsburgh, PA (K.H.P.); University of Texas Health Science Center at Houston (J.V.); University of Texas Medical Branch at Galveston (J.V.); and University General Hospital, Houston, TX (J.V.).
| | - Joseph Varon
- From the CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (K.H.P.); University of Pittsburgh Medical Center, Pittsburgh, PA (K.H.P.); University of Texas Health Science Center at Houston (J.V.); University of Texas Medical Branch at Galveston (J.V.); and University General Hospital, Houston, TX (J.V.)
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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.
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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
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Wise MP, Horn J, Åneman A, Nielsen N. Targeted temperature management after out-of-hospital cardiac arrest: certainties and uncertainties. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:459. [PMID: 25184963 PMCID: PMC4423770 DOI: 10.1186/s13054-014-0459-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/15/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Matt P Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Postbus 22700 NL-1100 DE, Amsterdam, The Netherlands.
| | - Anders Åneman
- Department of Intensive Care, Liverpool Hospital, Locked Bag 7103, Liverpool, BC NSW 1871, Australia.
| | - Niklas Nielsen
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, S Vallgatan 5, S-25187, Helsingborg, Sweden. .,Department of Clinical Sciences, Lund University, Box 117, S-22100, Lund, Sweden.
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