1
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Kim JH, Kim JG, Kang GH, Jang YS, Kim W, Choi HY, Lee Y, Ahn C. Target Temperature Management Effect on the Clinical Outcome of Patients with Out-of-Hospital Cardiac Arrest Treated with Extracorporeal Cardiopulmonary Resuscitation: A Nationwide Observational Study. J Pers Med 2024; 14:185. [PMID: 38392618 PMCID: PMC10890305 DOI: 10.3390/jpm14020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/28/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
This study aimed to investigate whether targeted temperature management (TTM) could enhance outcomes in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest. Using a nationwide OHCA registry, adult patients with witnessed OHCA of presumed cardiac origin who underwent ECPR at the emergency department between 2008 and 2021 were included. We examined the effect of ECPR with TTM on survival and neurological outcomes at hospital discharge using propensity score matching and multivariable logistic regression compared with patients treated with ECPR without TTM. Odds ratios and 95% confidence intervals were determined. A total of 399 ECPR cases were analyzed among 380,239 patients with OHCA. Of these, 330 underwent ECPR without TTM and 69 with TTM. After propensity score matching, 69 matched pairs of patients were included in the analysis. No significant differences in survival and good neurological outcomes between the two groups were observed. In the multivariable logistic regression, no significant differences were observed in survival and neurological outcomes between ECPR with and without TTM. Among the patients who underwent ECPR after OHCA, ECPR with TTM did not improve outcomes compared with ECPR without TTM.
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Affiliation(s)
- Jae-Hee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Jae-Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Gu-Hyun Kang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Yong-Soo Jang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Hyun-Young Choi
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Yoonje Lee
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea
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2
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Taccone FS, Dankiewicz J, Cariou A, Lilja G, Asfar P, Belohlavek J, Boulain T, Colin G, Cronberg T, Frat JP, Friberg H, Grejs AM, Grillet G, Girardie P, Haenggi M, Hovdenes J, Jakobsen JC, Levin H, Merdji H, Njimi H, Pelosi P, Rylander C, Saxena M, Thomas M, Young PJ, Wise MP, Nielsen N, Lascarrou JB. Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm: A Meta-Analysis. JAMA Neurol 2024; 81:126-133. [PMID: 38109117 PMCID: PMC10728804 DOI: 10.1001/jamaneurol.2023.4820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/06/2023] [Indexed: 12/19/2023]
Abstract
Importance International guidelines recommend body temperature control below 37.8 °C in unconscious patients with out-of-hospital cardiac arrest (OHCA); however, a target temperature of 33 °C might lead to better outcomes when the initial rhythm is nonshockable. Objective To assess whether hypothermia at 33 °C increases survival and improves function when compared with controlled normothermia in unconscious adults resuscitated from OHCA with initial nonshockable rhythm. Data Sources Individual patient data meta-analysis of 2 multicenter, randomized clinical trials (Targeted Normothermia after Out-of-Hospital Cardiac Arrest [TTM2; NCT02908308] and HYPERION [NCT01994772]) with blinded outcome assessors. Unconscious patients with OHCA and an initial nonshockable rhythm were eligible for the final analysis. Study Selection The study cohorts had similar inclusion and exclusion criteria. Patients were randomized to hypothermia (target temperature 33 °C) or normothermia (target temperature 36.5 to 37.7 °C), according to different study protocols, for at least 24 hours. Additional analyses of mortality and unfavorable functional outcome were performed according to age, sex, initial rhythm, presence or absence of shock on admission, time to return of spontaneous circulation, lactate levels on admission, and the cardiac arrest hospital prognosis score. Data Extraction and Synthesis Only patients who experienced OHCA and had a nonshockable rhythm with all causes of cardiac arrest were included. Variables from the 2 studies were available from the original data sets and pooled into a unique database and analyzed. Clinical outcomes were harmonized into a single file, which was checked for accuracy of numbers, distributions, and categories. The last day of follow-up from arrest was recorded for each patient. Adjustment for primary outcome and functional outcome was performed using age, gender, time to return of spontaneous circulation, and bystander cardiopulmonary resuscitation. Main Outcomes and Measures The primary outcome was mortality at 3 months; secondary outcomes included unfavorable functional outcome at 3 to 6 months, defined as a Cerebral Performance Category score of 3 to 5. Results A total of 912 patients were included, 490 from the TTM2 trial and 422 from the HYPERION trial. Of those, 442 had been assigned to hypothermia (48.4%; mean age, 65.5 years; 287 males [64.9%]) and 470 to normothermia (51.6%; mean age, 65.6 years; 327 males [69.6%]); 571 patients had a first monitored rhythm of asystole (62.6%) and 503 a presumed noncardiac cause of arrest (55.2%). At 3 months, 354 of 442 patients in the hypothermia group (80.1%) and 386 of 470 patients in the normothermia group (82.1%) had died (relative risk [RR] with hypothermia, 1.04; 95% CI, 0.89-1.20; P = .63). On the last day of follow-up, 386 of 429 in the hypothermia group (90.0%) and 413 of 463 in the normothermia group (89.2%) had an unfavorable functional outcome (RR with hypothermia, 0.99; 95% CI, 0.87-1.15; P = .97). The association of hypothermia with death and functional outcome was consistent across the prespecified subgroups. Conclusions and Relevance In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- After ROSC Network
| | - Josef Dankiewicz
- Cardiology Department, Lund University, Skåne University Hospital Lund, Lund, Sweden
| | - Alain Cariou
- After ROSC Network
- Department of Intensive Care, Paris Cité University, Cochin Hospital (APHP), Paris, France
| | - Gisela Lilja
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Pierre Asfar
- Département de Médecine Intensive Réanimation, CHU Angers, Angers, France
| | - Jan Belohlavek
- 2nd Department of Medicine, Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional, d’Orléans, Hôpital de la Source, Orléans, France
| | - Gwenhael Colin
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Tobias Cronberg
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Jean-Pierre Frat
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
- Skåne University Hospital, Intensive and Perioperative Care, Malmö, Sweden
| | - Anders M. Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Patrick Girardie
- Médecine Intensive Réanimation, CHU Lille, Université de Lille, Faculté de Médicine, Lille, France
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Jan Hovdenes
- Department of Anesthesia and Intensive Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Helena Levin
- Department of Research & Education, Lund University and Skåne University Hospital, Lund, Sweden
| | - Hamid Merdji
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France
- INSERM, UMR 1260, Regenerative Nanomedicine, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Paolo Pelosi
- Department of Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Manoj Saxena
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, St George Hospital, Kogarah, New South Wales, Australia
| | - Matt Thomas
- Department of Anaesthesia, Southmead Hospital, Bristol, United Kingdom
| | - Paul J. Young
- Department of Intensive Care, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Matt P. Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Niklas Nielsen
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Jean-Baptiste Lascarrou
- After ROSC Network
- Medecine Intensive Reanimation, CHU Nantes, Nantes, France
- Université Paris Cité, INSERM, PARCC, 75015 Paris, France
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3
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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4
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Fernandez Hernandez S, Barlow B, Pertsovskaya V, Maciel CB. Temperature Control After Cardiac Arrest: A Narrative Review. Adv Ther 2023; 40:2097-2115. [PMID: 36964887 PMCID: PMC10129937 DOI: 10.1007/s12325-023-02494-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/08/2023] [Indexed: 03/26/2023]
Abstract
Cardiac arrest (CA) is a critical public health issue affecting more than half a million Americans annually. The main determinant of outcome post-CA is hypoxic-ischemic brain injury (HIBI), and temperature control is currently the only evidence-based, guideline-recommended intervention targeting secondary brain injury. Temperature control is a key component of a post-CA care bundle; however, conflicting evidence challenges its wide implementation across the vastly heterogeneous population of CA survivors. Here, we critically appraise the available literature on temperature control in HIBI, detail how the evidence has been integrated into clinical practice, and highlight the complications associated with its use and the timing of neuroprognostication after CA. Future clinical trials evaluating different temperature targets, rates of rewarming, duration of cooling, and identifying which patient phenotype benefits from different temperature control methods are needed to address these prevailing knowledge gaps.
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Affiliation(s)
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann the Woodlands Medical Center, The Woodlands, TX, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Washington, DC, 20037, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, 32611, USA
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, 84132, USA
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5
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Jorge-Perez P, Nikolaou N, Donadello K, Khoury A, Behringer W, Hassager C, Boettiger B, Sionis A, Nolan J, Combes A, Quinn T, Price S, Grand J. Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM). EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:96-105. [PMID: 36454812 DOI: 10.1093/ehjacc/zuac153] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/15/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022]
Abstract
AIMS International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe. METHODS AND RESULTS A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions. CONCLUSION Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.
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Affiliation(s)
- Pablo Jorge-Perez
- Department of Cardiology, Canary Islands University Hospital, La Laguna, 38320 Santa Cruz de Tenerife, Spain
| | - Nikolaos Nikolaou
- Intensive Cardiac Care Unit, Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Katia Donadello
- Department of Anesthesia and Intensive Care B, Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, AOUI-University Hospital Integrated Trust of Verona, Policlinico G.B. Rossi, P.le L. Scuro, Verone, Italy
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France.,INSERM CIC 1431, Besançon University Hospital, Besançon, France
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna, Austria
| | - Christian Hassager
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, The Heart Center, Copenhagen, Denmark
| | - Bernd Boettiger
- Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.,European Resuscitation Council (ERC), Niel, Belgium.,German Resuscitation Council (GRC), Ulm, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Jerry Nolan
- Warwick Medical School, University of Warwick, Coventry, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Tom Quinn
- Kingston University and St. Georges, University of London, London, UK
| | - Susanna Price
- Departments of Cardiology and Critical Care, Royal Brompton & Harefield Hospitals, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Johannes Grand
- Department of Cardiology, Amager-Hvidovre Hospital, University Hospital of Copenhagen, Copenhagen, Denmark
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6
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Holgersson J, Meyer MAS, Dankiewicz J, Lilja G, Ullén S, Hassager C, Cronberg T, Wise MP, Bělohlávek J, Hovdenes J, Pelosi P, Erlinge D, Schrag C, Smid O, Brunetti I, Rylander C, Young PJ, Saxena M, Åneman A, Cariou A, Callaway C, Eastwood GM, Haenggi M, Joannidis M, Keeble TR, Kirkegaard H, Leithner C, Levin H, Nichol AD, Morgan MPG, Nordberg P, Oddo M, Storm C, Taccone FS, Thomas M, Bro-Jeppesen J, Horn J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher MJ, Friberg H, Nielsen N, Jakobsen JC. Hypothermic versus Normothermic Temperature Control after Cardiac Arrest. NEJM EVIDENCE 2022; 1:EVIDoa2200137. [PMID: 38319850 DOI: 10.1056/evidoa2200137] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: The evidence for temperature control for comatose survivors of cardiac arrest is inconclusive. Controversy exists as to whether the effects of hypothermia differ per the circumstances of the cardiac arrest or patient characteristics. METHODS: An individual patient data meta-analysis of the Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest (TTM) and Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trials was conducted. The intervention was hypothermia at 33°C and the comparator was normothermia. The primary outcome was all-cause mortality at 6 months. Secondary outcomes included poor functional outcome (modified Rankin scale score of 4 to 6) at 6 months. Predefined subgroups based on the design variables in the original trials were tested for interaction with the intervention as follows: age (older or younger than the median), sex (female or male), initial cardiac rhythm (shockable or nonshockable), time to return of spontaneous circulation (above or below the median), and circulatory shock on admission (presence or absence). RESULTS: The primary analyses included 2800 patients, with 1403 assigned to hypothermia and 1397 to normothermia. Death occurred for 691 of 1398 participants (49.4%) in the hypothermia group and 666 of 1391 participants (47.9%) in the normothermia group (relative risk with hypothermia, 1.03; 95% confidence interval [CI], 0.96 to 1.11; P=0.41). A poor functional outcome occurred for 733 of 1350 participants (54.3%) in the hypothermia group and 718 of 1330 participants (54.0%) in the normothermia group (relative risk with hypothermia, 1.01; 95% CI, 0.94 to 1.08; P=0.88). Outcomes were consistent in the predefined subgroups. CONCLUSIONS: Hypothermia at 33°C did not decrease 6-month mortality compared with normothermia after out-of-hospital cardiac arrest. (Funded by Vetenskapsrådet; ClinicalTrials.gov numbers NCT02908308 and NCT01020916.)
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Affiliation(s)
- Johan Holgersson
- Anesthesiology and Intensive Care, Department of Clinical Sciences, Helsingborg Hospital Lund, Lund University, Lund, Sweden
| | | | - Josef Dankiewicz
- Cardiology, Department of Clinical Sciences, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South, Skåne University Hospital, Lund, Sweden
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Tobias Cronberg
- Neurology, Department of Clinical Sciences, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Jan Bělohlávek
- Cardiovascular Medicine, Second Department of Medicine, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Hovdenes
- Division of Emergencies and Critical Care, Department of Anesthesiology, Oslo University Hospital, Rikshospitalet, Oslo
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, Scientific Institute for Research, Hospitalization and Healthcare for Oncology and Neurosciences, University of Genoa, Genoa, Italy
| | - David Erlinge
- Cardiology, Department of Clinical Sciences, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Claudia Schrag
- Intensive Care Department, Kantonspital St. Gallen, St. Gallen, Switzerland
| | - Ondrej Smid
- Cardiovascular Medicine, Second Department of Medicine, General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Iole Brunetti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, Scientific Institute for Research, Hospitalization and Healthcare for Oncology and Neurosciences, University of Genoa, Genoa, Italy
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paul J Young
- Intensive Care Unit, Medical Research Institute of New Zealand, Wellington Hospital, Wellington, New Zealand
| | - Manoj Saxena
- Division of Critical Care and Trauma, George Institute for Global Health, Sydney
| | - Anders Åneman
- Department of Intensive Care, Liverpool Hospital, Sydney
| | - Alain Cariou
- Cochin University Hospital, Descartes University of Paris, Paris
| | - Clifton Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh
| | - Glenn M Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Joannidis
- Division of Intensive and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon, United Kingdom
- Anglia Ruskin School of Medicine, Chelmsford, Essex, United Kingdom
| | - Hans Kirkegaard
- Department of Clinical Medicine, Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Christoph Leithner
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätzmedizin, Berlin
| | - Helena Levin
- Anesthesiology and Intensive Care, Department of Clinical Sciences, Skåne University Hospital Lund, Lund University, Lund, Sweden
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St. Vincent's University Hospital, Dublin
- School of Public Health and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Matt P G Morgan
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Per Nordberg
- Department of Clinical Science and Education, Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm
| | - Mauro Oddo
- Adult Intensive Care Medicine Service, Neuroscience Critical Care Research Group, Vaud University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Christian Storm
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels
| | - Matthew Thomas
- Department of Intensive Care, Bristol Royal Infirmary, Bristol, United Kingdom
| | - John Bro-Jeppesen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Michael Kuiper
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Tommaso Pellis
- Intensive Care Unit, Santa Maria degli Angeli, Pordenone, Italy
| | - Pascal Stammet
- Department of Intensive Care Medicine, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
- Department of Life Sciences and Medicine, Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Michael Jaeger Wanscher
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen
| | - Hans Friberg
- Anesthesia and Intensive Care, Department of Clinical Sciences, Skåne University Hospital Malmö, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Anesthesiology and Intensive Care, Department of Clinical Sciences, Helsingborg Hospital Lund, Lund University, Lund, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Copenhagen University Hospital, Copenhagen
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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7
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You JS, Kim JY, Yenari MA. Therapeutic hypothermia for stroke: Unique challenges at the bedside. Front Neurol 2022; 13:951586. [PMID: 36262833 PMCID: PMC9575992 DOI: 10.3389/fneur.2022.951586] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022] Open
Abstract
Therapeutic hypothermia has shown promise as a means to improving neurological outcomes at several neurological conditions. At the clinical level, it has been shown to improve outcomes in comatose survivors of cardiac arrest and in neonatal hypoxic ischemic encephalopathy, but has yet to be convincingly demonstrated in stroke. While numerous preclinical studies have shown benefit in stroke models, translating this to the clinical level has proven challenging. Major obstacles include cooling patients with typical stroke who are awake and breathing spontaneously but often have significant comorbidities. Solutions around these problems include selective brain cooling and cooling to lesser depths or avoiding hyperthermia. This review will cover the mechanisms of protection by therapeutic hypothermia, as well as recent progress made in selective brain cooling and the neuroprotective effects of only slightly lowering brain temperature. Therapeutic hypothermia for stroke has been shown to be feasible, but has yet to be definitively proven effective. There is clearly much work to be undertaken in this area.
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Affiliation(s)
- Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Youl Kim
- Department of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Midori A. Yenari
- Department of Neurology, The San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Midori A. Yenari
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8
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D'Amato SA, Kimberly WT, Mayer SA. Through the Looking Glass: The Paradoxical Evolution of Targeted Temperature Management for Comatose Survivors of Cardiac Arrest. Neurotherapeutics 2022; 19:1869-1877. [PMID: 36253510 PMCID: PMC9723025 DOI: 10.1007/s13311-022-01315-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 12/13/2022] Open
Abstract
For the past two decades, targeted temperature management (TTM) has been a staple in the care of comatose survivors following cardiac arrest. However, recent clinical trials have failed to replicate the benefit seen in earlier studies, bringing into question the very existence of such clinical practice. In this review, we explore clinical scenarios within critical care that appeared to share a similar fate, but in actuality changed the landscape of practice in a modern world. Accordingly, clinicians may apply these lessons to the utilization of TTM among comatose survivors following cardiac arrest, potentially paving way for a re-framing of clinical care amidst an environment where current data appears upside down in comparison to past successes.
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Affiliation(s)
- Salvatore A D'Amato
- Department of Neurosurgery, Neurocritical Care Fellowship Program, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.154, Houston, TX, 77030, USA.
| | - W Taylor Kimberly
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Stephan A Mayer
- Neurocritical Care and Emergency Neurology Services, Westchester Medical Center Health System, 100 Woods Road, Valhalla, NY, 10595, USA
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9
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Blanc A, Colin G, Cariou A, Merdji H, Grillet G, Girardie P, Coupez E, Dequin PF, Boulain T, Frat JP, Asfar P, Pichon N, Landais M, Plantefeve G, Quenot JP, Chakarian JC, Sirodot M, Legriel S, Massart N, Thevenin D, Desachy A, Delahaye A, Botoc V, Vimeux S, Martino F, Reignier J, Taccone FS, Lascarrou JB. Targeted Temperature Management After In-Hospital Cardiac Arrest: An Ancillary Analysis of Targeted Temperature Management for Cardiac Arrest With Nonshockable Rhythm Trial Data. Chest 2022; 162:356-366. [PMID: 35318006 DOI: 10.1016/j.chest.2022.02.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) currently is the only treatment with demonstrated efficacy in attenuating the harmful effects on the brain of ischemia-reperfusion injury after cardiac arrest. However, whether TTM is beneficial in the subset of patients with in-hospital cardiac arrest (IHCA) remains unclear. RESEARCH QUESTION Is TTM at 33 °C associated with better neurological outcomes after IHCA in a nonshockable rhythm compared with targeted normothermia (TN; 37 °C)? STUDY DESIGN AND METHODS We performed a post hoc analysis of data from the published Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm randomized controlled trial in 584 patients. We included the 159 patients with IHCA; 73 were randomized to 33 °C treatment and 86 were randomized to 37 °C treatment. The primary outcome was survival with a good neurologic outcome (cerebral performance category [CPC] score of 1 or 2) on day 90. Mixed multivariate adjusted logistic regression analysis was performed to determine whether survival with CPC score of 1 or 2 on day 90 was associated with type of temperature management after adjustment on baseline characteristics not balanced by randomization. RESULTS Compared with TN for 48 h, hypothermia at 33 °C for 24 h was associated with a higher percentage of patients who were alive with good neurologic outcomes on day 90 (16.4% vs 5.8%; P = .03). Day 90 mortality was not significantly different between the two groups (68.5% vs 76.7%; P = .24). By mixed multivariate analysis adjusted by Cardiac Arrest Hospital Prognosis score and circulatory shock status, hypothermia was associated significantly with good day 90 neurologic outcomes (OR, 2.40 [95% CI, 1.17-13.03]; P = .03). INTERPRETATION Hypothermia at 33 °C was associated with better day 90 neurologic outcomes after IHCA in a nonshockable rhythm compared with TN. However, the limited sample size resulted in wide CIs. Further studies of patients after cardiac arrest resulting from any cause, including IHCA, are needed.
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Affiliation(s)
- Alexiane Blanc
- Médecine Intensive Réanimation, University Hospital Center, Nantes, France
| | - Gwenhael Colin
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon, France
| | - Alain Cariou
- Paris Cardiovascular Research Center, INSERM U970, Paris, France; Medical Intensive Care Unit, Cochin University Hospital Center, Paris, France; AfterROSC Network, Cochin University Hospital Center, Paris, France
| | - Hamid Merdji
- Faculté de Médecine Université de Strasbourg (UNISTRA) and the Service de Médecine Intensive Réanimation (H. Merdji), Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France; UMR 1260, Regenerative Nano Medecine, INSERM, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Guillaume Grillet
- Medical Intensive Care Unit, South Brittany General Hospital Center, Lorient, France
| | - Patrick Girardie
- Médecine Intensive Réanimation, CHU Lille, and the Université de Lille, Faculté de Médicine, Lille, France
| | - Elisabeth Coupez
- Medical Intensive Care Unit, University Hospital Center, Clermond-Ferrand, France
| | - Pierre-François Dequin
- Medical Intensive Care Unit, University Hospital Center, Tours, France; Inserm UMR 1100-Centre d'Étude des Pathologies Respiratoires, Tours University, Tours, France
| | - Thierry Boulain
- Medical Intensive Care Unit, Regional Hospital Center, Orleans, France
| | - Jean-Pierre Frat
- Medical Intensive Care Unit, University Hospital Center, Poitiers, France; INSERM, CIC-1402, Équipe ALIVE, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - Pierre Asfar
- Medical Intensive Care Unit, University Hospital Center, Angers, France
| | - Nicolas Pichon
- AfterROSC Network, Cochin University Hospital Center, Paris, France; Service de Réanimation Polyvalente, University Hospital Center, Limoges, France; CIC 1435, University Hospital Center, Limoges, France
| | - Mickael Landais
- Medical-Surgical Intensive Care Unit, General Hospital Center, Le Mans, France
| | - Gaëtan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Center, Argenteuil, France
| | | | | | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, General Hospital Center, Annecy, France
| | - Stéphane Legriel
- AfterROSC Network, Cochin University Hospital Center, Paris, France; Medical-Surgical Intensive Care Unit, Versailles Hospital, Versailles, France
| | - Nicolas Massart
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Brieuc, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, General Hospital Center, Lens, France
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, General Hospital Center, Angouleme, France
| | - Arnaud Delahaye
- Medical-Surgical Intensive Care Unit, General Hospital Center, Rodez, France
| | - Vlad Botoc
- Medical-Surgical Intensive Care Unit, General Hospital Center, Saint Malo, France
| | - Sylvie Vimeux
- Medical-Surgical Intensive Care Unit, General Hospital Center, Montauban, France
| | - Frederic Martino
- Medical Intensive Care Unit, University Hospital Center, Pointe-à-Pitre, France
| | - Jean Reignier
- Médecine Intensive Réanimation, University Hospital Center, Nantes, France
| | - F S Taccone
- Erasmus University Hospital, Free University of Brussels, Brussels, Belgium
| | - J B Lascarrou
- Médecine Intensive Réanimation, University Hospital Center, Nantes, France; Paris Cardiovascular Research Center, INSERM U970, Paris, France; AfterROSC Network, Cochin University Hospital Center, Paris, France.
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10
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Lascarrou JB, Guichard E, Reignier J, Le Gouge A, Pouplet C, Martin S, Lacherade JC, Colin G. Impact of rewarming rate on interleukin-6 levels in patients with shockable cardiac arrest receiving targeted temperature management at 33 °C: the ISOCRATE pilot randomized controlled trial. Crit Care 2021; 25:434. [PMID: 34920723 PMCID: PMC8680374 DOI: 10.1186/s13054-021-03842-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/24/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose While targeted temperature management (TTM) has been recommended in patients with shockable cardiac arrest (CA) and suggested in patients with non-shockable rhythms, few data exist regarding the impact of the rewarming rate on systemic inflammation. We compared serum levels of the proinflammatory cytokine interleukin-6 (IL6) measured with two rewarming rates after TTM at 33 °C in patients with shockable out-of-hospital cardiac arrest (OHCA). Methods ISOCRATE was a single-center randomized controlled trial comparing rewarming at 0.50 °C/h versus 0.25 °C/h in patients coma after shockable OHCA in 2016–2020. The primary outcome was serum IL6 level 24–48 h after reaching 33 °C. Secondary outcomes included the day-90 Cerebral Performance Category (CPC) and the 48-h serum neurofilament light-chain (NF-L) level. Results We randomized 50 patients. The median IL6 area-under-the-curve was similar between the two groups (12,389 [7256–37,200] vs. 8859 [6825–18,088] pg/mL h; P = 0.55). No significant difference was noted in proportions of patients with favorable day-90 CPC scores (13/25 patients at 0.25 °C/h (52.0%; 95% CI 31.3–72.2%) and 13/25 patients at 0.50 °C/h (52.0%; 95% CI 31.3–72.2%; P = 0.99)). Median NF-L levels were not significantly different between the 0.25 °C/h and 0.50 °C/h groups (76.0 pg mL, [25.5–3074.0] vs. 192 pg mL, [33.6–4199.0]; P = 0.43; respectively). Conclusion In our RCT, rewarming from 33 °C at 0.25 °C/h, compared to 0.50 °C/h, did not decrease the serum IL6 level after shockable CA. Further RCTs are needed to better define the optimal TTM strategy for patients with CA. Trial registration ClinicalTrials.gov, NCT02555254. Registered September 14, 2015. Take-Home Message: Rewarming at a rate of 0.25 °C/h, compared to 0.50 °C, did not result in lower serum IL6 levels after achievement of hypothermia at 33 °C in patients who remained comatose after shockable cardiac arrest. No associations were found between the slower rewarming rate and day-90 functional outcomes or mortality. 140-character Tweet: Rewarming at 0.25 °C versus 0.50 °C did not decrease serum IL6 levels after hypothermia at 33 °C in patients comatose after shockable cardiac arrest. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03842-9.
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Affiliation(s)
- Jean-Baptiste Lascarrou
- Médecine Intensive Reanimation, University Hospital Center, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 1, France. .,Paris Cardiovascular Research Center, INSERM U970, Paris, France. .,AfterROSC Network, Paris, France.
| | | | - Jean Reignier
- Médecine Intensive Reanimation, University Hospital Center, 30 Boulevard Jean Monnet, 44093, Nantes Cedex 1, France
| | | | - Caroline Pouplet
- Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
| | - Stéphanie Martin
- Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
| | | | - Gwenhael Colin
- AfterROSC Network, Paris, France.,Médecine Intensive Reanimation, District Hospital Center, La Roche-sur-Yon, France
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11
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Scquizzato T, Young PJ, Landoni G, Zaraca L, Zangrillo A. Randomised trials of temperature management in cardiac arrest: Are we observing the Zeno's paradox of the Tortoise and Achilles? Crit Care 2021; 25:409. [PMID: 34838116 PMCID: PMC8626907 DOI: 10.1186/s13054-021-03826-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy. .,Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Luisa Zaraca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy.,Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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12
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Halenarova K, Belliato M, Lunz D, Peluso L, Broman LM, Malfertheiner MV, Pappalardo F, Taccone FS. Predictors of poor outcome after extra-corporeal membrane oxygenation for refractory cardiac arrest (ECPR): A post hoc analysis of a multicenter database. Resuscitation 2021; 170:71-78. [PMID: 34822932 DOI: 10.1016/j.resuscitation.2021.11.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The objective was to assess predictors for unfavorable neurological outcome (UO) in out-of-hospital (OHCA) and in-hospital (IHCA) cardiac arrest patients treated with Extracorporeal cardiopulmonary resuscitation (ECPR). METHODS A post hoc analysis of retrospective data from five European ECPR centers (January 2012-December 2016) was performed. The primary composite endpoint was 3-month UO defined as survival with a cerebral performance category (CPC) of 3-4 or death (CPC 5). RESULTS A total of 413 patients treated with ECPR were included (median age was 57 [48-65] years, male gender 78%): 61% of patients (n = 250) suffered OHCA. The median time from collapse to ECMO placement was 63 [45-82] minutes. Overall, 81% patients (n = 333) showed unfavorable UO, which was higher in OHCA patients (90% vs 66%), as compared to IHCA. In OHCA, prolonged time from collapse to ECMO initiation (OR 1.02, p < 0.01) and higher ECMO blood flow (OR 1.99, p = 0.01) were associated with UO while initial shockable rhythm (OR 0.04, p < 0.01), previous heart disease (OR 0.20, p < 0.01) and pre-hospital hypothermia (OR 0.08, p < 0.01) had a protective role. In IHCA, prolonged time from arrest to ECMO implantation (OR 1.02, p = 0.03), high lactate level on admission (OR 1.15, p < 0.01) and higher body weight (OR 1.03, p < 0.01) were independently associated with UO. CONCLUSIONS IHCA and OHCA patients receiving ECPR have different predictors of UO at presentation, suggesting that selection criteria for ECPR should be decided according to the location of CA. After ECMO initiation, ECMO blood flow management and mean arterial pressure targets might also impact neurological recovery.
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Affiliation(s)
- Katarina Halenarova
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mirko Belliato
- UOC Anestesia e Rianimazione 2 Cardiopolmonare Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Dirk Lunz
- Department of Anesthesiology and Intensive Care University Hospital Regensburg, Regensburg, Germany
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital Department of Physiology and Pharmacology Karolinska Institutet, Stockholm, Sweden
| | | | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Hospital Vita-Salute University, Milan, Italy; CardioThoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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13
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Targeted Temperature Management after Cardiac Arrest: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. J Clin Med 2021; 10:jcm10173943. [PMID: 34501392 PMCID: PMC8432025 DOI: 10.3390/jcm10173943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/28/2021] [Accepted: 08/29/2021] [Indexed: 12/11/2022] Open
Abstract
Target temperature management (TTM) in cardiac arrest (CA) survivors is recommended after hospital admission for its possible beneficial effects on survival and neurological outcome. Whether a lower target temperature (i.e., 32–34 °C) improves outcomes is unclear. We conducted a systematic review and meta-analysis on Pubmed and EMBASE to evaluate the effects on mortality and neurologic outcome of TTM at 32–34 °C as compared to controls (patients cared with “actively controlled” or “uncontrolled” normothermia). Results were analyzed via risk ratios (RR) and 95% confidence intervals (CI). Eight randomized controlled trials (RCTs) were included. TTM at 32–34 °C was compared to “actively controlled” normothermia in three RCTs and to “uncontrolled” normothermia in five RCTs. TTM at 32–34 °C does not improve survival as compared to normothermia (RR:1.06 (95%CI 0.94, 1.20), p = 0.36; I2 = 39%). In the subgroup analyses, TTM at 32–34 °C is associated with better survival when compared to “uncontrolled” normothermia (RR: 1.31 (95%CI 1.07, 1.59), p = 0.008) but shows no beneficial effects when compared to “actively controlled” normothermia (RR: 0.97 (95%CI 0.90, 1.04), p = 0.41). TTM at 32–34 °C does not improve neurological outcome as compared to normothermia (RR: 1.17 (95%CI 0.97, 1.41), p = 0.10; I2 = 60%). TTM at 32–34 °C increases the risk of arrhythmias (RR: 1.35 (95%CI 1.16, 1.57), p = 0.0001, I2 = 0%). TTM at 32–34 °C does not improve survival nor neurological outcome after CA and increases the risk of arrhythmias.
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