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Jeppesen AN, Duez C, Kirkegaard H, Grejs AM, Hvas AM. Fibrinolysis in Cardiac Arrest Patients Treated with Hypothermia. Ther Hypothermia Temp Manag 2023; 13:112-119. [PMID: 36473198 DOI: 10.1089/ther.2022.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hypothermia affects coagulation, but the effect of hypothermia on fibrinolysis is not clarified. Imbalance in the fibrinolytic system may lead to increased risk of bleeding or thrombosis. Our aim was to investigate if resuscitated cardiac arrest patients treated with hypothermia had an unbalanced fibrinolysis. A prospective cohort study, including 82 patients were treated with hypothermia at 33°C ± 1°C after out-of-hospital cardiac arrest. Blood samples were collected at 24 hours (hypothermia) and at 72 hours (normothermia). Samples were analyzed for fibrin D-dimer, tissue plasminogen activator (tPA), plasminogen, plasminogen activator Inhibitor-1 (PAI-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and an in-house dynamic fibrin clot formation and lysis assay.Compared with normothermia, hypothermia significantly increased plasminogen activity (mean difference = 10.4%, 95% confidence interval [CI] 7.9-12.9), p < 0.001), PAI-1 levels (mean difference = 275 ng/mL, 95% CI 203-348, p < 0.001), and tPA levels (mean difference = 1.0 ng/mL, 95% CI 0.2-1.7, p = 0.01). No differences between hypothermia and normothermia were found in TAFI activity (p = 0.59) or in the fibrin D-dimer levels (p = 0.08). The fibrin clot lysis curves showed three different patterns: normal-, flat-, or resistant clot lysis curve. At hypothermia 45 (55%) patients had a resistant clot lysis curve and 33 (44%) patients had a resistant clot lysis curve at normothermia (p = 0.047). Comatose, resuscitated, cardiac arrest patients treated with hypothermia express an inhibited fibrinolysis even after rewarming. This could potentially increase the thromboembolic risk. ClinicalTrials.gov ID: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Anesthesia Section, Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Christophe Duez
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Otolaryngology, Head and Neck Surgery, and Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Anders Morten Grejs
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Larsen AI, Grejs AM, Vistisen ST, Strand K, Skadberg Ø, Jeppesen AN, Duez CHV, Kirkegaard H, Søreide E. Kinetics of 2 different high-sensitive troponins during targeted temperature management in out-of-hospital cardiac arrest patients with acute myocardial infarction: a post hoc sub-study of a randomised clinical trial. BMC Cardiovasc Disord 2022; 22:342. [PMID: 35907787 PMCID: PMC9339199 DOI: 10.1186/s12872-022-02778-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/13/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Short term hypothermia has been suggested to have cardio protective properties in acute myocardial infarction (AMI) by reducing infarct size as assessed by troponins. There are limited data on the kinetics of these biomarkers in comatose out-of-hospital cardiac arrest (OHCA) patients, with and without AMI, undergoing targeted temperature management (TTM) in the ICU.
Purpose The aim of this post hoc analyses was to evaluate and compare the kinetics of two high-sensitivity cardiac troponins in OHCA survivors, with and without acute myocardial infarction (AMI), during TTM of different durations [24 h (standard) vs. 48 h (prolonged)]. Methods In a sub-cohort (n = 114) of the international, multicentre, randomized controlled study “TTH48” we measured high-sensitive troponin T (hs-cTnT), high-sensitive troponin I (hs-cTnI) and CK-MB at the following time points: Arrival, 24 h, 48 h and 72 h from reaching the target temperature range of 33 ± 1 °C. All patients diagnosed with an AMI at the immediate coronary angiogram (CAG)—18 in the 24-h group and 25 in the 48-h group—underwent PCI with stent implantation. There were no stent thromboses.
Results Both the hs-cTnT and hs-cTnI changes over time were highly influenced by the cause of OHCA (AMI vs. non-AMI). In contrast to non-AMI patients, both troponins remained elevated at 72 h in AMI patients. There was no difference between the two time-differentiated TTM groups in the kinetics for the two troponins.
Conclusion In comatose OHCA survivors with an aetiology of AMI levels of both hs-cTnI and hs-cTnT remained elevated for 72 h, which is in contrast to the well-described kinetic profile of troponins in normotherm AMI patients. There was no difference in kinetic profile between the two high sensitive assays. Different duration of TTM did not influence the kinetics of the troponins. Trial registration: Clinicaltrials.gov Identifier: NCT01689077, 20/09/2012.
Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02778-4.
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Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Sciences, University of Bergen, Bergen, Norway.
| | - Anders Morten Grejs
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Tilma Vistisen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Laboratory of Clinical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Anni Nørgaard Jeppesen
- Division for Heart- Lung- and Vascular Surgery, Anaesthesiology section, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe H V Duez
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Research Centre for Emergency Medicine, Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Eldar Søreide
- Department of Clinical Sciences, University of Bergen, Bergen, Norway.,Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway
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Paramanathan S, Grejs AM, Søreide E, Duez CHV, Jeppesen AN, Reinertsen ÅJ, Strand K, Kirkegaard H. Quantitative pupillometry in comatose out-of-hospital cardiac arrest patients: A post-hoc analysis of the TTH48 trial. Acta Anaesthesiol Scand 2022; 66:880-886. [PMID: 35488868 PMCID: PMC9545910 DOI: 10.1111/aas.14078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/01/2022] [Accepted: 04/16/2022] [Indexed: 12/01/2022]
Abstract
Background Quantitative pupillometry is an objective method to examine pupil reaction and subsequently grade the response on a neurological pupil index (NPi) scale from 0 to 5. The aim of the present sub‐study was to explore the long‐term prognostic value of NPi in comatose out‐of‐hospital cardiac arrest patients undergoing targeted temperature management (TTM). Methods This planned sub‐study of the “Targeted temperature management for 48 versus 24 h and neurological outcome after out‐of‐hospital cardiac arrest: A randomized clinical trial.” NPi was assessed from admission and throughout day 3 and linked to the Cerebral Performance Categories score at 6 months. We compared the prognostic performance of NPi in 65 patients randomized to a target temperature of 33 ± 1°C for 24 or 48 h. Results The NPi values were not different between TTM groups (p > .05). When data were pooled, NPi was strongly associated with neurological outcome at day 1 with a mean NPi of 3.6 (95% CI 3.4–3.8) versus NPi 3.9 (3.6–4.1) in the poor versus good outcome group, respectively (p < .01). At day 2, NPi values were 3.6 (3.1–4.0) and 4.1 (3.9–4.2) (p = .01) and at day 3, the values were 3.3 (2.6–4.0) and 4.3 (4.1–4.6), respectively (p < .01). The prognostic ability of NPi, defined by area under the receiver operating characteristic curve was best at day three. Conclusion Quantitative pupillometry measured by NPi was not different in the two TTM groups, but overall, significantly associated with good and poor neurological outcomes at 6 months. NPI has a promising diagnostic accuracy, but larger studies are warranted.
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Affiliation(s)
| | - Anders Morten Grejs
- Department of Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group Stavanger University Hospital Stavanger Norway
- Department of Clinical Medicine University of Bergen Bergen Norway
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus Denmark
| | - Åse Johanne Reinertsen
- Critical Care and Anesthesiology Research Group Stavanger University Hospital Stavanger Norway
| | - Kristian Strand
- Department of Intensive Care Stavanger University Hospital Stavanger Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital and Department of Clinical Medicine Aarhus University Aarhus Denmark
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Bach HM, Duez CHV, Jeppesen AN, Strand K, Søreide E, Kirkegaard H, Grejs AM. MR-proANP and NT-proBNP During Targeted Temperature Management Following Out-of-Hospital Cardiac Arrest: A Post hoc Analysis of the TTH48 Trial. Ther Hypothermia Temp Manag 2021; 12:82-89. [PMID: 34375135 DOI: 10.1089/ther.2021.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We aimed to evaluate the effect of prolonged targeted temperature management (TTM) in patients with out-of-hospital cardiac arrest (OHCA) on the levels of midregional pro-atrial natriuretic peptide (MR-proANP) and N-terminal pro b-type natriuretic peptide (NT-proBNP) and assess their potential as prognostic biomarkers. A preplanned post hoc analysis of "Targeted temperature management for 48 h vs 24 h and neurologic outcome after out-of-hospital cardiac arrest: A randomized clinical trial (TTH48 trial)," where patients were randomized to TTM at 33°C ± 1°C of standard duration (24 hours) versus prolonged (48 hours). Blood samples were drawn from patients with OHCA at two Scandinavian university hospitals at admission to the ICU and at 24, 48, and 72 hours after reaching the target temperature. Primary outcome was levels of MR-proANP and NT-proBNP. Secondary outcome was cerebral performance category (CPC 1-5) at 6 months. Samples from 114 patients were analyzed. Prolonged TTM significantly decreased the levels of MR-proANP and NT-proBNP at 48 hours compared with standard 24 hours-TTM (p < 0.01). However, there were no significant differences at other time points. Patients with poor outcome (CPC 3-5) had a statistically significantly increased MR-proANP level at 24 hours (p < 0.01) and 72 hours (p < 0.01) compared with the good outcome group (CPC 1-2). Prognostic performance was best at 24 hours for both MR-proANP and NT-proBNP; with an AUC of 0.73 (confidence interval [95% CI]: 0.63-0.83) and 0.72 (95 % CI: 0.59-0.85), respectively. Prolonged TTM lowered the levels of both MR-proANP and NT-proBNP at 48 hours. MR-proANP may add prognostic information in postcardiac arrest patients. ClinicalTrials.gov ID: NCT01689077.
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Affiliation(s)
| | | | | | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Eldar Søreide
- Critical Care and Anesthesiology Research Group and Department of Clinical Medicine, Stavanager University Hospital, Stavanger, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Intensive Care, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Factors Associated With Rebound Hyperthermia After Targeted Temperature Management in Out-of-Hospital Cardiac Arrest Patients: An Explorative Substudy of the Time-Differentiated Therapeutic Hypothermia in Out-of-Hospital Cardiac Arrest Survivors Trial. Crit Care Explor 2021; 3:e0458. [PMID: 34250498 PMCID: PMC8263323 DOI: 10.1097/cce.0000000000000458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: To investigate rebound hyperthermia following targeted temperature management after cardiac arrest and its impact on functional outcome. DESIGN: Post hoc analysis. SETTING: Ten European ICUs. PATIENTS: Patients included in the time-differentiated therapeutic hypothermia in out-of-hospital cardiac arrest survivors trial treated with targeted temperature management at 33°C for 48 or 24 hours. Favorable functional outcome was defined as a Cerebral Performance Category of 1 or 2 at 6 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 338 included patients, 103 (30%) experienced rebound hyperthermia defined as a maximum temperature after targeted temperature management and rewarming exceeding 38.5°C. Using multivariate logistic regression analysis, increasing age (odds ratio, 0.97; 95% CI, 0.95–0.99; p = 0.02) and severe acute kidney injury within 72 hours of ICU admission (odds ratio, 0.35; 95% CI, 0.13–0.91; p = 0.03) were associated with less rebound hyperthermia, whereas male gender (odds ratio, 3.94; 95% CI, 1.34–11.57; p = 0.01), highest C-reactive protein value (odds ratio, 1.04; 95% CI, 1.01–1.07; p = 0.02), and use of mechanical chest compression during cardiopulmonary resuscitation (odds ratio, 2.00; 95% CI, 1.10–3.67; p = 0.02) were associated with more rebound hyperthermia. Patients with favorable functional outcome spent less time after rewarming over 38.5°C (2.5% vs 6.3%; p = 0.03), 39°C (0.14% vs 2.7%; p < 0.01), and 39.5°C (0.03% vs 0.71%; p < 0.01) when compared with others. Median time to rebound hyperthermia was longer in the unfavorable functional outcome group (33.2 hr; interquartile range, 14.3–53.0 hr vs 6.5 hr; interquartile range, 2.2–34.1; p < 0.01). In a predefined multivariate binary logistic regression model, rebound hyperthermia was associated with decreased odds of favorable functional outcome (odds ratio, 0.42; 95% CI, 0.22–0.79). CONCLUSIONS: One-third of targeted temperature management patients experience rebound hyperthermia, and it is more common in younger male patients with an aggravated inflammatory response and those treated with a mechanical chest compression device. Later onset of rebound hyperthermia and temperatures exceeding 38.5°C associate with unfavorable outcome.
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Evald L, Brønnick K, Duez CHV, Grejs AM, Jeppesen AN, Søreide E, Kirkegaard H, Nielsen JF. Younger age is associated with higher levels of self-reported affective and cognitive sequelae six months post-cardiac arrest. Resuscitation 2021; 165:148-153. [PMID: 33887400 DOI: 10.1016/j.resuscitation.2021.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/01/2021] [Accepted: 04/10/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Affective and cognitive sequelae are frequently reported in cardiac arrest survivors; however, little is known about the risk factors. We assessed the hypothesis that self-reported affective and cognitive sequelae six months after OHCA may be associated with demography, acute care and cerebral outcome. METHODS This is a sub-study of the multicentre "Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: A Randomised Clinical Trial" (the TTH48 trial) investigating the effect of prolonged TTM at 33 ± 1 °C. We invited patients with good outcome on the Cerebral Performances Categories (CPC score ≤ 2) to answer questionnaires on anxiety, depression, emotional distress, perceived stress and cognitive failures six months post OHCA. RESULTS In total 79 of 111 eligible patients were included in the analysis. There were no significant differences in baseline characteristics between the included group and the group lost to follow-up. Younger age was a negative predictor across all self-reported outcomes, even when controlling for gender, ROSC time, treatment allocation, cognitive impairment and global outcome (CPC 1 or 2). Female gender was a predictor of anxiety, though this should be interpreted cautiously as only eight women participated. A CPC score of 2 score was a negative predictor of self-reported affective outcomes, albeit not for self-reported cognitive failures. CONCLUSION Younger age was associated with higher levels of self-reported affective and cognitive sequelae six months post OHCA. Female gender may be associated with self-reported anxiety. A higher CPC score may be a proxy for self-reported affective sequelae.
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Affiliation(s)
- Lars Evald
- Hammel Neurorehabilitation Clinic and University Research Centre, Hammel, Denmark.
| | - Kolbjørn Brønnick
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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Grand J, Hassager C, Skrifvars MB, Tiainen M, Grejs AM, Jeppesen AN, Duez CHV, Rasmussen BS, Laitio T, Nee J, Taccone F, Søreide E, Kirkegaard H. Haemodynamics and vasopressor support during prolonged targeted temperature management for 48 hours after out-of-hospital cardiac arrest: a post hoc substudy of a randomised clinical trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:132–141. [PMID: 32551835 DOI: 10.1177/2048872620934305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/16/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Comatose patients admitted after out-of-hospital cardiac arrest frequently experience haemodynamic instability and anoxic brain injury. Targeted temperature management is used for neuroprotection; however, targeted temperature management also affects patients' haemodynamic status. This study assessed the haemodynamic status of out-of-hospital cardiac arrest survivors during prolonged (48 hours) targeted temperature management at 33°C. METHODS Analysis of haemodynamic and vasopressor data from 311 patients included in a randomised, clinical trial conducted in 10 European hospitals (the TTH48 trial). Patients were randomly allocated to targeted temperature management at 33°C for 24 (TTM24) or 48 (TTM48) hours. Vasopressor and haemodynamic data were reported hourly for 72 hours after admission. Vasopressor load was calculated as norepinephrine (µg/kg/min) plus dopamine(µg/kg/min/100) plus epinephrine (µg/kg/min). RESULTS After 24 hours, mean arterial pressure (mean±SD) was 74±9 versus 75±9 mmHg (P=0.19), heart rate was 57±16 and 55±14 beats/min (P=0.18), vasopressor load was 0.06 (0.03-0.15) versus 0.08 (0.03-0.15) µg/kg/min (P=0.22) for the TTM24 and TTM48 groups, respectively. From 24 to 48 hours, there was no difference in mean arterial pressure (Pgroup=0.32) or lactate (Pgroup=0.20), while heart rate was significantly lower (average difference 5 (95% confidence interval 2-8) beats/min, Pgroup<0.0001) and vasopressor load was significantly higher in the TTM48 group (Pgroup=0.005). In a univariate Cox regression model, high vasopressor load was associated with mortality in univariate analysis (hazard ratio 1.59 (1.05-2.42) P=0.03), but not in multivariate analysis (hazard ratio 0.77 (0.46-1.29) P=0.33). CONCLUSIONS In this study, prolonged targeted temperature management at 33°C for 48 hours was associated with higher vasopressor requirement but no sign of any detrimental haemodynamic effects.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet - Copenhagen University Hospital, Denmark
| | - Markus B Skrifvars
- Department of Anesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Finland
| | - Marjaana Tiainen
- Department of Anesthesia and Intensive Care, Helsinki University Hospital and University of Helsinki, Finland
| | - Anders M Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Denmark
| | | | | | - Bodil S Rasmussen
- Anaesthesiology and Intensive Care, Aalborg University Hospital, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Finland
| | - Jens Nee
- Department of Intensive Care Medicine, Charité - Universitaetsmedizin Berlin, Germany
| | | | - Eldar Søreide
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital and Aarhus University, Denmark
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More than a death marker-Serum biomarkers identify future cognitive impairment. Resuscitation 2021; 162:435-436. [PMID: 33838168 DOI: 10.1016/j.resuscitation.2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
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Brønnick K, Evald L, Duez CHV, Grejs AM, Jeppesen AN, Kirkegaard H, Nielsen JF, Søreide E. Biomarker prognostication of cognitive impairment may be feasible even in out-of hospital cardical arrest survivors with good neurological outcome. Resuscitation 2021; 162:396-402. [PMID: 33631291 DOI: 10.1016/j.resuscitation.2021.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/04/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients surviving out-of hospital cardicac arrest, with good neurological outcome according to Cerebral Performance Category, frequently have neuropsychological impairment. We studied whether biomarker data (S-100b and neuron-specific enolase) obtained during the ICU stay predicted cognitive impairment 6 months after resuscitation. METHODS Patients (N = 79) with a CPC-score ≤2 were recruited from two trial sites taking part in the TTH48 trial comparing targeted temperature management (TTM) for 48 h vs. 24 h at 33 ± 1 °C. We assessed patients 6 months after the OHCA. We measured biomarkers S-100b and NSE at arrival and at 24, 48 and 72 h after reaching the target temperature of 33 ± 1 °C. Four cognitive domain z-scores were calculated, and global cognitive impairment was defined as z < -1.67 on at least 3 out of 13 cognitive tests. Non-parametric correlations were used to assess the relationship between cognitive domain and biomarkers. ROC curves were used to assess prediction of cognitive impairment from the biomarkers. Logistic regression was used to investigate whether TTM duration moderated biomarker prediction of cognitive impairment. RESULTS Cognitive impairment was present in 22% of the patients with memory impairment being the most common. The biomarkers correlated significantly with several cognitive domain scores and NSE at 48 h predicted cognitive impairment with 100% sensitivity and 56% specificity. The predictive properties of NSE at 48 h was unaffected by duration of TTM. CONCLUSIONS Early biomarker prognostication of cognitive impairment is feasible even in OHCA survivors with good neurological outcome as defined by CPC. NSE at 48 h predicted cognitive impairment.
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Affiliation(s)
- Kolbjørn Brønnick
- Department of Public Health, University of Stavanger, Stavanger, Norway; Centre for Age-Related Medicine (SESAM), Helse Stavanger, Stavanger, Norway.
| | - Lars Evald
- Hammel Neurorehabilitation Centre and University Research Clinic, Hammel, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Emergency Department and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | | | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Jensen TH, Juhl-Olsen P, Nielsen BRR, Heiberg J, Duez CHV, Jeppesen AN, Frederiksen CA, Kirkegaard H, Grejs AM. Echocardiographic parameters during prolonged targeted temperature Management in out-of-hospital Cardiac Arrest Survivors to predict neurological outcome - a post-hoc analysis of the TTH48 trial. Scand J Trauma Resusc Emerg Med 2021; 29:37. [PMID: 33608045 PMCID: PMC7893899 DOI: 10.1186/s13049-021-00849-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Transthoracic echocardiographic (TTE) indices of myocardial function among survivors of out-of-hospital cardiac arrest (OHCA) have been related to neurological outcome; however, results are inconsistent. We hypothesized that changes in average peak systolic mitral annular velocity (s') from 24 h (h) to 72 h following start of targeted temperature management (TTM) predict six-month neurological outcome in comatose OHCA survivors. METHODS We investigated the association between peak systolic velocity of the mitral plane (s') and six-month neurological outcome in a population of 99 patients from a randomised controlled trial comparing TTM at 33 ± 1 °C for 24 h (h) (n = 47) vs. 48 h (n = 52) following OHCA (TTH48-trial). TTE was conducted at 24 h, 48 h, and 72 h after reaching target temperature. The primary outcome was 180 days neurological outcome assessed by Cerebral Performance Category score (CPC180) and the primary TTE outcome measure was s'. Secondary outcome measures were left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), e', E/e' and tricuspid annular plane systolic excursion (TAPSE). RESULTS Across all three scan time points s' was not associated with neurological outcome (ORs: 24 h: 1.0 (95%CI: 0.7-1.4, p = 0.98), 48 h: 1.13 (95%CI: 0.9-1.4, p = 0.34), 72 h: 1.04 (95%CI: 0.8-1.4, p = 0.76)). LVEF, GLS, E/e', and TAPSE recorded on serial TTEs following OHCA were neither associated with nor did they predict CPC180. Estimated median e' at 48 h following TTM was 5.74 cm/s (95%CI: 5.27-6.22) in patients with good outcome (CPC180 1-2) vs. 4.95 cm/s (95%CI: 4.37-5.54) in patients with poor outcome (CPC180 3-5) (p = 0.04). CONCLUSIONS s' assessed on serial TTEs in comatose survivors of OHCA treated with TTM was not associated with CPC180. Our findings suggest that serial TTEs in the early post-resuscitation phase during TTM do not aid the prognostication of neurological outcome following OHCA. TRIAL REGISTRATION NCT02066753 . Registered 14 February 2014 - Retrospectively registered.
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Affiliation(s)
- Thomas Hvid Jensen
- Department of Cardiology, Viborg Regional Hospital, Heibergs Alle 2K, 8800, Viborg, Denmark.
| | - Peter Juhl-Olsen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | | | - Johan Heiberg
- Centre of Head and Orthopaedics Rigshospitalet, Copenhagen, Denmark
| | | | | | | | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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11
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Hästbacka J, Kirkegaard H, Søreide E, Taccone FS, Rasmussen BS, Storm C, Kjaergaard J, Laitio T, Duez CHV, Jeppesen AN, Grejs AM, Skrifvars MB. Severe or critical hypotension during post cardiac arrest care is associated with factors available on admission - a post hoc analysis of the TTH48 trial. J Crit Care 2020; 61:186-190. [PMID: 33181415 DOI: 10.1016/j.jcrc.2020.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE We explored whether severe or critical hypotension can be predicted, based on patient and resuscitation characteristics in out-of-hospital cardiac arrest (OHCA) patients. We also explored the association of hypotension with mortality and neurological outcome. MATERIALS AND METHODS We conducted a post hoc analysis of the TTH48 study (NCT01689077), where 355 out-of-hospital cardiac arrest (OHCA) patients were randomized to targeted temperature management (TTM) treatment at 33 °C for either 24 or 48 h. We recorded hypotension, according to four severity categories, within four days from admission. We used multivariable logistic regression analysis to test association of admission data with severe or critical hypotension. RESULTS Diabetes mellitus (OR 3.715, 95% CI 1.180-11.692), longer ROSC delay (OR 1.064, 95% CI 1.022-1.108), admission MAP (OR 0.960, 95% CI 0.929-0.991) and non-shockable rhythm (OR 5.307, 95% CI 1.604-17.557) were associated with severe or critical hypotension. Severe or critical hypotension was associated with increased mortality and poor neurological outcome at 6 months. CONCLUSIONS Diabetes, non-shockable rhythm, longer delay to ROSC and lower admission MAP were predictors of severe or critical hypotension. Severe or critical hypotension was associated with poor outcome.
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Affiliation(s)
- Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Bodil Steen Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni N Jeppesen
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders M Grejs
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lee J, Oh JS, Zhu JH, Hong S, Park SH, Kim JH, Kim H, Seo M, Kim K, Lee DH, Jung HH, Park J, Oh YM, Choi S, Choi KH. High HbA1c is associated with decreased 6-month survival and poor outcomes after out-of-hospital cardiac arrest: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2020; 28:88. [PMID: 32883318 PMCID: PMC7470436 DOI: 10.1186/s13049-020-00782-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/27/2020] [Indexed: 02/04/2023] Open
Abstract
Background To evaluate the associations between glycated hemoglobin (HbA1c) at admission and 6-month mortality and outcomes after out-of-hospital cardiac arrest (OHCA) treated by hypothermic targeted temperature management (TTM). Methods This single-center retrospective cohort study included adult OHCA survivors who underwent hypothermic TTM from December 2011 to December 2019. High HbA1c at admission was defined as a level higher than 6%. Poor neurological outcomes were defined as cerebral performance category scores of 3–5. The primary outcome was 6-month mortality. The secondary outcome was the 6-month neurological outcome. Descriptive statistics, log-rank tests, and multivariable regression modeling were used for data analysis. Results Of the 302 patients included in the final analysis, 102 patients (33.8%) had HbA1c levels higher than 6%. The high HbA1c group had significantly worse 6-month survival (12.7% vs. 37.5%, p < 0.001) and 6-month outcomes (89.2% vs. 73.0%, p = 0.001) than the non-high HbA1c group. Kaplan-Meier analysis and the log-rank test showed that the survival time was significantly shorter in the patients with HbA1c > 6% than in those with HbA1c ≤6%. In the multivariable logistic regression analysis, HbA1c > 6% was independently associated with 6-month mortality (OR 5.85, 95% CI 2.26–15.12, p < 0.001) and poor outcomes (OR 4.18, 95% CI 1.41–12.40, p < 0.001). Conclusions This study showed that HbA1c higher than 6% at admission was associated with increased 6-month mortality and poor outcomes in OHCA survivors treated with hypothermic TTM. Poor long-term glycemic management may have prognostic significance after cardiac arrest.
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Affiliation(s)
- Junhaeng Lee
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea.
| | - Jong Ho Zhu
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungyoup Hong
- Department of Emergency Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Sang Hyun Park
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon-si, Republic of Korea
| | - Hyungsoo Kim
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Mingu Seo
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Kiwook Kim
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Doo Hyo Lee
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Hyun Ho Jung
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Jungtaek Park
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Young Min Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Semin Choi
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
| | - Kyoung Ho Choi
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu-si, Republic of Korea
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Schroeder DC, Maul AC, Guschlbauer M, Finke SR, de la Puente Bethencourt D, Becker I, Padosch SA, Hohn A, Annecke T, Böttiger BW, Sterner-Kock A, Herff H. Intravascular Cooling Device Versus Esophageal Heat Exchanger for Mild Therapeutic Hypothermia in an Experimental Setting. Anesth Analg 2020; 129:1224-1231. [PMID: 30418241 DOI: 10.1213/ane.0000000000003922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Targeted temperature management is a standard therapy for unconscious survivors of cardiac arrest. To date, multiple cooling methods are available including invasive intravascular cooling devices (IVDs), which are widely used in the clinical setting. Recently, esophageal heat exchangers (EHEs) have been developed providing cooling via the esophagus that is located close to the aorta and inferior vena cava. The objective was to compare mean cooling rates, as well as differences, to target temperature during maintenance and the rewarming period of IVD and EHE. METHODS The study was conducted in 16 female domestic pigs. After randomization to either IVD or EHE (n = 8/group), core body temperature was reduced to 33°C. After 24 hours of maintenance (33°C), animals were rewarmed using a target rate of 0.25°C/h for 10 hours. All cooling phases were steered by a closed-loop feedback system between the internal jugular vein and the chiller. After euthanasia, laryngeal and esophageal tissue was harvested for histopathological examination. RESULTS Mean cooling rates (4.0°C/h ± 0.4°C/h for IVD and 2.4°C/h ± 0.3°C/h for EHE; P < .0008) and time to target temperature (85.1 ± 9.2 minutes for IVD and 142.0 ± 21.2 minutes for EHE; P = .0008) were different. Mean difference to target temperature during maintenance (0.07°C ± 0.05°C for IVD and 0.08°C ± 0.10°C for EHE; P = .496) and mean rewarming rates (0.2°C/h ± 0.1°C/h for IVD and 0.3°C/h ± 0.2°C/h for EHE; P = .226) were similar. Relevant laryngeal or esophageal tissue damage could not be detected. There were no significant differences in undesired side effects (eg, bradycardia or tachycardia, hypokalemia or hyperkalemia, hypoglycemia or hyperglycemia, hypotension, overcooling, or shivering). CONCLUSIONS After insertion, target temperatures could be reached faster by IVD compared to EHE. Cooling performance of IVD and EHE did not significantly differ in maintaining target temperature during a targeted temperature management process and in active rewarming protocols according to intensive care unit guidelines in this experimental setting.
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Affiliation(s)
- Daniel C Schroeder
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alexandra C Maul
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Maria Guschlbauer
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany.,Decentral Animal Facility, University Hospital of Cologne, Cologne, Germany
| | - Simon-Richard Finke
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, University Hospital of Cologne, Cologne, Germany
| | - Stephan A Padosch
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Andreas Hohn
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Annecke
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernd W Böttiger
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Anja Sterner-Kock
- Center for Experimental Medicine, University Hospital of Cologne, Cologne, Germany
| | - Holger Herff
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
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14
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Skrifvars MB, Soreide E, Sawyer KN, Taccone FS, Toome V, Storm C, Jeppesen A, Grejs A, Duez CHV, Tiainen M, Rasmussen BS, Laitio T, Hassager C, Kirkegaard H. Hypothermic to ischemic ratio and mortality in post-cardiac arrest patients. Acta Anaesthesiol Scand 2020; 64:546-555. [PMID: 31830304 DOI: 10.1111/aas.13528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND We studied the associations between ischemia and hypothermia duration, that is, the hypothermic to ischemic ratio (H/I ratio), with mortality in patients included in a trial on two durations of targeted temperature management (TTM) at 33°C. METHODS The TTH48 (NCT01689077) trial compared 24 and 48 hours of TTM in patients after cardiac arrest. We calculated the hypothermia time from return of spontaneous circulation (ROSC) until the patient reached 37°C after TTM and the ischemic time from CA to ROSC. We compared continuous variables with the Mann-Whitney U test. Using COX regression, we studied the independent association of the logarithmically transformed H/I ratio and time to death as well as interaction between time to ROSC, hypothermia duration, and intervention group. We visualized the predictive ability of variables with receiver operating characteristic curve analysis. RESULTS Of the 338 patients, 237 (70%) survived for 6 months. The H/I ratio was 155 (IQR 111-238) in survivors and 114 (IQR 80-169) in non-survivors (P < .001). In a Cox regression model including factors associated with outcome in univariate analysis, the logarithmically transformed H/I ratio was a significant predictor of outcome (hazard ratio 0.52 (0.37-0.72, P = .001)). After removing an outlier, we found no interaction between time to ROSC and intervention group (P = .55) or hypothermia duration in quartiles (P = .07) with mortality. There was no significant difference in the area under the curve (AUC) between time to ROSC and H/I ratio (ΔAUC 0.03 95% CI -0.006-0.07, P = .10). CONCLUSIONS We did not find any consistent evidence of a modification of the effect of TTM based on ischemia duration.
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Affiliation(s)
- Markus B. Skrifvars
- Department of Emergency Care and Services University of HelsinkiHelsinki University Hospital Helsinki Finland
- Department of Anesthesiology, Intensive Care and Pain Medicine University of HelsinkiHelsinki University Hospital Helsinki Finland
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group Stavanger University Hospital Stavanger Norway
- Department Clinical Medicine University of Bergen Bergen Norway
| | - Kelly N. Sawyer
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh PA USA
| | - Fabio S. Taccone
- Department of Intensive Care Erasme HospitalUniversité Libre de Bruxelles Brussels Belgium
| | - Valdo Toome
- Department of Intensive Cardiac Care North Estonia Medical Centre Tallinn Estonia
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Anni Jeppesen
- Department of Anaesthesiology Aarhus University Hospital Aarhus Denmark
| | - Anders Grejs
- Department of Intensive Care Medicine Aarhus University Hospital Aarhus Denmark
| | - Christophe H. V. Duez
- Research Center for Emergency Medicine Department of Emergency Medicine and Department of Clinical Medicine Aarhus University Hospital and Aarhus University Aarhus Denmark
| | - Marjaana Tiainen
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Bodil S. Rasmussen
- Department of Anesthesiology and Intensive Care Medicine Aalborg University HospitalClinical InstituteAalborg University Aalborg Denmark
| | - Timo Laitio
- Division of Perioperative Services Intensive Care Medicine and Pain Management Turku University Hospital and University of Turku Finland
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine Department of Emergency Medicine and Department of Clinical Medicine Aarhus University Hospital and Aarhus University Aarhus Denmark
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15
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Holm A, Kirkegaard H, Taccone F, Søreide E, Grejs A, Duez C, Jeppesen A, Toome V, Hassager C C, Rasmussen BS, Laitio T, Storm C, Hästbacka J, Skrifvars MB. Cold fluids for induction of targeted temperature management: A sub-study of the TTH48 trial. Resuscitation 2020; 148:90-97. [PMID: 31962179 DOI: 10.1016/j.resuscitation.2019.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/28/2019] [Accepted: 11/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pre-intensive care unit (ICU) induction of targeted temperature management (TTM) with cold intravenous (i.v.) fluids does not appear to improve outcomes after in out-of-hospital cardiac arrest (OHCA). We hypothesized that this may be due to ineffective cooling and side effects. METHODS A post hoc analysis of a sub-group of patients (n = 352) in the TTH48 trial (NCT01689077) who received or did not receive pre-ICU cooling using cold i.v. fluids. Data collection included patient characteristics, cardiac arrest factors, cooling methods, side effects and continuous core temperature measurements. The primary endpoint was the time to target temperature (TTT, <34 °C), and the secondary endpoints included the incidence of circulatory side effects, abnormal electrolyte levels and hypoxia within the first 24 h of ICU care. A difference of 1 h in the TTT was determined as clinically significant a priori. RESULTS Of 352 patients included in the present analysis, 110 received pre-ICU cold fluids. The median time to the return of spontaneous circulation (ROSC) and TTT in the pre-ICU cold fluids group was longer than that of the group that did not receive pre-ICU cold fluids (318 vs. 281 min, p < 0.01). In a linear regression model including the treatment centre, body mass index (BMI), chronic heart failure, diabetes mellitus and time to ROSC, the use of pre-ICU cold i.v. fluids was not associated with a shorter time to the target temperature (standardized beta coefficient: 0.06, 95% CI for B -49 and 16, p = 0.32). According to the receipt or not of pre-ICU cold i.v. fluids, there was no difference in the proportion of patients with hypoxia on ICU admission (1.8% vs. 3.3%, p = 0.43) or the proportion of patients with electrolyte abnormalities (hyponatremia: 1.8% vs. 2.9% p = 0.54; hypokalaemia: 1.8% vs. 4.5%, p = 0.20). Furthermore, there was no difference in hospital mortality between the groups. CONCLUSIONS The initiation of TTM with cold i.v. fluids before ICU arrival did not decrease the TTT. We detected no significant between-group difference in mortality or the incidence of side effects according to the administration or not of pre-ICU cold i.v fluids.
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Affiliation(s)
- Aki Holm
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anders Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Christophe Duez
- Research Center for Emergency Medicine, Department of Emergency Medicine and Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Jeppesen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Valdo Toome
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Christian Hassager C
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Bodil S Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Timo Laitio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johanna Hästbacka
- Department of Anesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Markus B Skrifvars
- Department of Anesthesiology, Intensive Care and Paine Medicine, University of Helsinki and Helsinki University Hospital, Finland; Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland.
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Park JH, Wee JH, Choi SP, Oh JH, Cheol S. Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia. Clin Exp Emerg Med 2019; 6:9-18. [PMID: 30781939 PMCID: PMC6453696 DOI: 10.15441/ceem.17.273] [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: 09/11/2017] [Accepted: 11/14/2017] [Indexed: 12/03/2022] Open
Abstract
Objective Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC). Methods From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using Glasgow-Pittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy. Results A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and category-free net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours). Conclusion Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.
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Affiliation(s)
- Jeong Ho Park
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jung Hee Wee
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae Hun Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Shin Cheol
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Post resuscitation prognostication by EEG in 24 vs 48 h of targeted temperature management. Resuscitation 2019; 135:145-152. [DOI: 10.1016/j.resuscitation.2018.10.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 11/22/2022]
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18
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Evald L, Brønnick K, Duez CHV, Grejs AM, Jeppesen AN, Søreide E, Kirkegaard H, Nielsen JF. Prolonged targeted temperature management reduces memory retrieval deficits six months post-cardiac arrest: A randomised controlled trial. Resuscitation 2018; 134:1-9. [PMID: 30572070 DOI: 10.1016/j.resuscitation.2018.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/09/2018] [Accepted: 12/10/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cognitive sequelae, most frequently memory, attention, and executive dysfunctions, occur commonly in out-of-hospital cardiac arrest (OHCA) survivors. Targeted temperature management (TTM) following OHCA is associated with improved cognitive function. However, the relationship between the duration of TTM and cognitive outcome remains unclear. We hypothesised that OHCA survivors that were subjected to prolonged TTM of 48 h (TTM48) would exhibit better cognitive functions compared to those subjected to standard TTM of 24 h (TTM24) six months post-OHCA. METHODS A predefined, cognitive post-hoc sub-study was conducted on the multicentre clinical trial: "Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after out-of-hospital cardiac arrest: A Randomised Clinical Trial" (the TTH48 trial). OHCA survivors with perceived good cognitive outcome (CPC score ≤ 2) were invited to a neuropsychological assessment of memory, attention, and executive functions six months post-OHCA. RESULTS In total, 79 patients were included in the study. Multivariate regression analysis revealed that TTM48 was associated with a significant better performance on three of 13 cognitive tests specific to memory retrieval after adjusting for age at follow-up and time to return of spontaneous circulation. Overall, patients in the TTM24 group were almost three times more likely (RR = 2.9 (95% CI 1.1-7.4)), p = 0.02) to be cognitively impaired. CONCLUSIONS This study reports an association between the duration of TTM and cognitive outcome. In OHCA survivors with perceived good cognitive outcome (CPC ≤ 2), TTM48 was associated with reduced memory retrieval deficits and lower relative risk of cognitive impairment six months after OHCA compared to standard TTM24. ClinicalTrials.gov (identifier: NCT01689077).
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Affiliation(s)
- Lars Evald
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark.
| | - Kolbjørn Brønnick
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
| | - Christophe Henri Valdemar Duez
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans Kirkegaard
- Research Centre for Emergency Medicine and Department of Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark
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Haugaard SF, Jeppesen AN, Troldborg A, Kirkegaard H, Thiel S, Hvas AM. The complement lectin pathway after cardiac arrest. Scand J Immunol 2018; 88:e12680. [PMID: 29885250 DOI: 10.1111/sji.12680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/05/2018] [Indexed: 02/06/2023]
Abstract
The lectin pathway (LP) of the complement system may initiate inflammatory reactions when body tissue is altered. We aimed to investigate the levels of the LP proteins in out-of-hospital cardiac arrest patients, and to compare these with healthy individuals. Furthermore, we aimed to clarify whether the duration of targeted temperature management influenced LP protein levels, and we further examined whether LP proteins were associated with 30-day mortality. We included 82 patients resuscitated from out-of-hospital cardiac arrest. The patients were randomly assigned to 24 or 48 hours of targeted temperature management at 33 ± 1°C. Blood samples were obtained 22, 46 and 70 hours after target temperature was reached. Levels of the LP proteins (mannan-binding lectin [MBL], M-ficolin, H-ficolin, collectin liver 1 [CL-L1], MBL-associated serine protease 1 [MASP-1], MASP-2, MASP-3 and MBL-associated protein of 44 kDa [MAp44]) were measured using time-resolved immunofluorometric assays. Data from 82 gender matched healthy individuals were used for comparison. Levels of CL-L1, MASP-1, MASP-2 and MAp44 were significantly higher, whereas M-ficolin levels were significantly lower in cardiac arrest patients compared with healthy individuals. MASP-2, MASP-3 and M-ficolin levels changed significantly when comparing 24 and 48 hours of targeted temperature management. The LP protein levels were not different between 30-day survivors and non-survivors after cardiac arrest. The differences in LP protein levels between patients and healthy individuals may indicate that cardiac arrest patients have an activated LP. Overall, the LP protein levels were not influenced by the duration of targeted temperature management, and the levels were not associated with 30-day mortality.
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Affiliation(s)
- S F Haugaard
- Department of Clinical Biochemistry, Centre for Hemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
| | - A N Jeppesen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - A Troldborg
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - H Kirkegaard
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - S Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - A-M Hvas
- Department of Clinical Biochemistry, Centre for Hemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
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Abstract
Therapeutic hypothermia, also referred to as targeted temperature management, has been a component of the postcardiac arrest treatment guidelines since 2010. Although almost a decade has passed since its inclusion in the postarrest guidelines, many unanswered questions remain regarding selection of the appropriate patient population, optimal target temperature, ideal window of time in which to initiate therapy after arrest, most efficient, safe, and accurate equipment choice for inducing and maintaining hypothermia, most effective duration of treatment, and rate of cooling or rewarming. On a national and international level, critical care nurses are in a unique position to participate in research that will define targeted temperature management protocols and practices. Nurses are also ideal for standardizing the targeted temperature management policy and protocol locally and nationally based on current available evidence. This review aims to serve 2 purposes: first, to provide a broad update on the current clarifications and limitations per research findings on target temperature management therapy; second, to explain how critical care nurses can use this updated information to improve outcomes for their patients with cardiac arrest.
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Neuron-specific enolase and S-100b in prolonged targeted temperature management after cardiac arrest: A randomised study. Resuscitation 2017; 122:79-86. [PMID: 29175384 DOI: 10.1016/j.resuscitation.2017.11.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 11/14/2017] [Accepted: 11/19/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND We aimed to investigate the impact of prolonged targeted temperature management (TTM) in cardiac arrest patients on release of serum levels of NSE and S-100b and their prognostic performances. METHODS This is a substudy of the Targeted Temperature Management for 24 vs 48h trial. NSE and S-100b levels were analysed retrospectively in serum samples collected upon admission, at 24, 48, and 72h after reaching the target temperature of 33±1°C. The primary outcome was biomarker serum concentrations and secondary outcome was the cerebral performance category score after 6 months. RESULTS 115 patients from two centres were analysed. NSE and S-100b levels did not differ between TTM groups at any single time-point. Poor outcome patients had higher biomarker levels at 24, 48, and 72h: NSE: 9.73 (7.2; 10.9) versus 20.40 (12.7; 27.2), 8.86 (6.6; 9.6) versus 17.47 (11.1; 37.3) and 6.23 (5.3; 8.5) versus 31.05 (12.8; 52.5) respectively and S-100b: 0.09 (0.07; 0.11) versus 0.23 (0.19; 0.39), 0.08 (0.07; 0.09) versus 0.18 (0.15; 0.33) and 0.07 (0.06; 0.08) versus 0.13 (0.09; 0.23). The daily changes in NSE from admission to Day 2 after the cardiac arrest (CA) were also related to the outcome (p=0.003 and p=0.02). The best prediction of outcome was found at 72h for NSE and at 24h as well as 48h for S100b. CONCLUSIONS No clinically relevant differences were found in the levels of NSE or S-100b between standard and prolonged TTM. Prognostic reliability of NSE and S-100b was unaltered by prolonged TTM.
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Jeppesen AN, Hvas AM, Grejs AM, Duez C, Ilkjær S, Kirkegaard H. Platelet aggregation during targeted temperature management after out-of-hospital cardiac arrest: A randomised clinical trial. Platelets 2017; 29:504-511. [DOI: 10.1080/09537104.2017.1336213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Christophe Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Research Centre for Emergency Medicine, Aarhus University Hospital, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Kirkegaard H, Søreide E, de Haas I, Pettilä V, Taccone FS, Arus U, Storm C, Hassager C, Nielsen JF, Sørensen CA, Ilkjær S, Jeppesen AN, Grejs AM, Duez CHV, Hjort J, Larsen AI, Toome V, Tiainen M, Hästbacka J, Laitio T, Skrifvars MB. Targeted Temperature Management for 48 vs 24 Hours and Neurologic Outcome After Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2017; 318:341-350. [PMID: 28742911 PMCID: PMC5541324 DOI: 10.1001/jama.2017.8978] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE International resuscitation guidelines recommend targeted temperature management (TTM) at 33°C to 36°C in unconscious patients with out-of-hospital cardiac arrest for at least 24 hours, but the optimal duration of TTM is uncertain. OBJECTIVE To determine whether TTM at 33°C for 48 hours results in better neurologic outcomes compared with currently recommended, standard, 24-hour TTM. DESIGN, SETTING, AND PARTICIPANTS This was an international, investigator-initiated, blinded-outcome-assessor, parallel, pragmatic, multicenter, randomized clinical superiority trial in 10 intensive care units (ICUs) at 10 university hospitals in 6 European countries. Three hundred fifty-five adult, unconscious patients with out-of-hospital cardiac arrest were enrolled from February 16, 2013, to June 1, 2016, with final follow-up on December 27, 2016. INTERVENTIONS Patients were randomized to TTM (33 ± 1°C) for 48 hours (n = 176) or 24 hours (n = 179), followed by gradual rewarming of 0.5°C per hour until reaching 37°C. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month neurologic outcome, with a Cerebral Performance Categories (CPC) score of 1 or 2 used to define favorable outcome. Secondary outcomes included 6-month mortality, including time to death, the occurrence of adverse events, and intensive care unit resource use. RESULTS In 355 patients who were randomized (mean age, 60 years; 295 [83%] men), 351 (99%) completed the trial. Of these patients, 69% (120/175) in the 48-hour group had a favorable outcome at 6 months compared with 64% (112/176) in the 24-hour group (difference, 4.9%; 95% CI, -5% to 14.8%; relative risk [RR], 1.08; 95% CI, 0.93-1.25; P = .33). Six-month mortality was 27% (48/175) in the 48-hour group and 34% (60/177) in the 24-hour group (difference, -6.5%; 95% CI, -16.1% to 3.1%; RR, 0.81; 95% CI, 0.59-1.11; P = .19). There was no significant difference in the time to mortality between the 48-hour group and the 24-hour group (hazard ratio, 0.79; 95% CI, 0.54-1.15; P = .22). Adverse events were more common in the 48-hour group (97%) than in the 24-hour group (91%) (difference, 5.6%; 95% CI, 0.6%-10.6%; RR, 1.06; 95% CI, 1.01-1.12; P = .04). The median length of intensive care unit stay (151 vs 117 hours; P < .001), but not hospital stay (11 vs 12 days; P = .50), was longer in the 48-hour group than in the 24-hour group. CONCLUSIONS AND RELEVANCE In unconscious survivors from out-of-hospital cardiac arrest admitted to the ICU, targeted temperature management at 33°C for 48 hours did not significantly improve 6-month neurologic outcome compared with targeted temperature management at 33°C for 24 hours. However, the study may have had limited power to detect clinically important differences, and further research may be warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01689077.
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Affiliation(s)
- Hans Kirkegaard
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Inge de Haas
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Ville Pettilä
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Denmark
| | - Christina Ankjær Sørensen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Susanne Ilkjær
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Jakob Hjort
- Department of Clinical Medicine, Aarhus University, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Norway
- Department of Clinical Science, University of Bergen, Norway
| | - Valdo Toome
- Department of Anesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Marjaana Tiainen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Finland
| | - Johanna Hästbacka
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Timo Laitio
- Department of Anesthesiology and Intensive Care, Turku University Hospital and University of Turku, Finland
| | - Markus B. Skrifvars
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Australia
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Jeppesen AN, Hvas AM, Duez CHV, Grejs AM, Ilkjær S, Kirkegaard H. Prolonged targeted temperature management compromises thrombin generation: A randomised clinical trial. Resuscitation 2017; 118:126-132. [PMID: 28602694 DOI: 10.1016/j.resuscitation.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 11/16/2022]
Abstract
AIM To investigate whether prolonged compared with standard duration of targeted temperature management (TTM) compromises coagulation. METHODS Comatose survivors after out-of-hospital cardiac arrest (n=82) were randomised to standard (24h) or prolonged (48h) duration of TTM at 33±1°C. Blood samples were drawn 22, 46 and 70h after attaining the target temperature. Samples were analysed for rotational thromboelastometry (ROTEM® (EXTEM®, INTEM®, FIBTEM® and HEPTEM®)) and thrombin generation using the Calibrated Automated Thrombogram® assay. RESULTS With the 22-h sample, we revealed no difference between groups in the ROTEM® and thrombin generation results beside a slightly higher EXTEM® and INTEM® maximum velocity in the prolonged group (p-values≤0.04). With the 46-h sample, ROTEM® showed no differences when using EXTEM®; however, 11% (p<0.01) longer clotting time and 12% (p<0.01) longer time to maximum velocity were evident in the prolonged group than in the standard group when using INTEM®. The prolonged group had reduced thrombin generation compared with the standard group as indicated by 30% longer lag time (p=0.04), 106nM decreased peak concentration (p<0.001), 36% longer time to peak (p=0.01) and 411 nM*minute decreased endogenous thrombin potential (p<0.001). With the 70-h sample, no differences in ROTEM® results were found between groups. However, the prolonged group had reduced thrombin generation indicated by longer lag time, decreased peak concentration and longer time to peak (all p-values≤0.02) compared with the standard group. CONCLUSION Prolonged TTM in post-cardiac arrest patients impairs thrombin generation. ClinicalTrials.gov identifier: NCT02258360.
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Affiliation(s)
- Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark.
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Research Centre for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 30, 8000 Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Grejs AM, Nielsen BRR, Juhl-Olsen P, Gjedsted J, Sloth E, Heiberg J, Frederiksen CA, Jeppesen AN, Duez CHV, Hamre PD, Søreide E, Kirkegaard H. Effect of prolonged targeted temperature management on left ventricular myocardial function after out-of-hospital cardiac arrest − A randomised, controlled trial. Resuscitation 2017; 115:23-31. [DOI: 10.1016/j.resuscitation.2017.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 12/20/2022]
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Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:52. [PMID: 28536893 DOI: 10.1007/s11936-017-0548-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO2, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
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Grejs AM, Gjedsted J, Thygesen K, Lassen JF, Rasmussen BS, Jeppesen AN, Duez CHV, Søreide E, Kirkegaard H. The Extent of Myocardial Injury During Prolonged Targeted Temperature Management After Out-of-Hospital Cardiac Arrest. Am J Med 2017; 130:37-46. [PMID: 27477668 DOI: 10.1016/j.amjmed.2016.06.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 12/23/2022]
Abstract
AIM The aim of this study is to evaluate the extent of myocardial injury by cardiac biomarkers during prolonged targeted temperature management of 24 hours vs 48 hours after out-of-hospital cardiac arrest. METHODS This randomized Scandinavian multicenter study compares the extent of myocardial injury quantified by area under the curve (AUC) of cardiac biomarkers during prolonged targeted temperature management at 33°C ± 1°C of 24 hours and 48 hours, respectively. Through a period of 2.5 years, 161 comatose out-of-hospital cardiac arrest patients were randomized to targeted temperature management for 24 hours (n = 77) or 48 hours (n = 84). The AUC was calculated using both high-sensitivity cardiac troponin T (hs-cTnTAUC) and creatine kinase-myocardial band (CK-MBAUC) that were based upon measurements of these biomarkers every 6 hours upon admission until 96 hours after reaching target temperature. RESULTS The median hs-cTnTAUC of 33,827 ng/L/h (interquartile range [IQR] 11,366-117,690) of targeted temperature management at 24 hours did not differ significantly from that of 28,973 ng/L/h (IQR 10,656-163,655) at 48 hours. In contrast, the median CK-MBAUC of 1829 μg/L/h (IQR 800-6799) during targeted temperature management at 24 hours was significantly lower than that of 2428 μg/L/h (IQR 1163-10,906) within targeted temperature management at 48 hours, P <.05. CONCLUSION This study of comatose out-of-hospital cardiac arrest survivors showed no difference between the extents of myocardial injury estimated by hs-cTnTAUC of prolonged targeted temperature management of 48 hours vs 24 hours, although the CK-MBAUC was significantly higher during 48 hours vs 24 hours. Hence, it seems unlikely that the duration of targeted temperature management has a beneficial effect on the extent of myocardial injury after out-of-hospital cardiac arrest, and may even have a worsening effect.
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Affiliation(s)
- Anders Morten Grejs
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Jakob Gjedsted
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | | | - Jens Flensted Lassen
- Department of Cardiology, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Bodil Steen Rasmussen
- Department of Anesthesiology and Intensive Care Medicine, Aalborg University, Denmark; Department of Clinical Medicine, Aalborg University, Denmark
| | - Anni Nørgaard Jeppesen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Christophe Henri Valdemar Duez
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Eldar Søreide
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Pilarczyk K, Trummer G, Haake N, Markewitz A. Neue Leitlinien zur kardiopulmonalen Reanimation und ihre Implikationen für die herzchirurgische Intensivmedizin. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0105-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kirkegaard H, Pedersen AR, Pettilä V, Hjort J, Rasmussen BS, de Haas I, Nielsen JF, Ilkjær S, Kaltoft A, Jeppesen AN, Grejs AM, Duez CHV, Larsen AI, Toome V, Arus U, Taccone FS, Storm C, Laitio T, Skrifvars MB, Søreide E. A statistical analysis protocol for the time-differentiated target temperature management after out-of-hospital cardiac arrest (TTH48) clinical trial. Scand J Trauma Resusc Emerg Med 2016; 24:138. [PMID: 27894327 PMCID: PMC5127087 DOI: 10.1186/s13049-016-0334-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The TTH48 trial aims to determine whether prolonged duration (48 hours) of targeted temperature management (TTM) at 33 (±1) °C results in better neurological outcomes compared to standard duration (24 hours) after six months in comatose out-of-hospital cardiac arrest (OHCA) patients. METHODS TTH48 is an investigator-initiated, multicentre, assessor-blinded, randomised, controlled superiority trial of 24 and 48 hours of TTM at 33 (±1) ° C performed in 355 comatose OHCA patients aged 18 to 80 years who were admitted to ten intensive care units (ICUs) in six Northern European countries. The primary outcome of the study is the Cerebral Performance Category (CPC) score observed at six months after cardiac arrest. CPC scores of 1 and 2 are defined as good neurological outcomes, and CPC scores of 3, 4 and 5 are defined as poor neurological outcomes. The secondary outcomes are as follows: mortality within six months after cardiac arrest, CPC at hospital discharge, Glasgow Coma Scale (GCS) score on day 4, length of stay in ICU and at hospital and the presence of any adverse events such as cerebral, circulatory, respiratory, gastrointestinal, renal, metabolic measures, infection or bleeding. With the planned sample size, we have 80% power to detect a 15% improvement in good neurological outcomes at a two-sided statistical significance level of 5%. DISCUSSION We present a detailed statistical analysis protocol (SAP) that specifies how primary and secondary outcomes should be evaluated. We also predetermine covariates for adjusted analyses and pre-specify sub-groups for sensitivity analyses. This pre-planned SAP will reduce analysis bias and add validity to the findings of this trial on the effect of length of TTM on important clinical outcomes after cardiac arrest. TRIAL REGISTRATION ClinicalTrials.gov: NCT01689077 , 17 September 2012.
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Affiliation(s)
- Hans Kirkegaard
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Roer Pedersen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Ville Pettilä
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University, Helsinki, Finland
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jakob Hjort
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Inge de Haas
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jørgen Feldbæk Nielsen
- Hammel Neurorehabilitation Centre and University Research Clinic, Aarhus University, Aarhus, Denmark
| | - Susanne Ilkjær
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Kaltoft
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anni Nørgaard Jeppesen
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Morten Grejs
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Christophe Henri Valdemar Duez
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Research Center for Emergency Medicine, Aarhus University, Aarhus, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Valdo Toome
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Urmet Arus
- Department of Intensive Cardiac Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasmus Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Storm
- Department of Internal Medicine, Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Timo Laitio
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Turku, Finland
| | - Markus B Skrifvars
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
- Division of Intensive Care, Department of Anaesthesiology and Intensive Care Medicine, Helsinki University, Helsinki, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Monash, Australia
| | - Eldar Søreide
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Kitagawa RS, Storm C, Nonogi H. Clinical Applications of Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2016; 6:160-163. [PMID: 27824528 DOI: 10.1089/ther.2016.29019.rsk] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ryan S Kitagawa
- 1 The Vivian L. Smith Department of Neurosurgery, University of Texas , Houston, Texas
| | - Christian Storm
- 2 Klinik fur Nephrologie und Internistische Intensivmedizin Charité Universitätsmedizin , Berlin, Germany
| | - Hiroshi Nonogi
- 3 Department of Cardiology Shizuoka General Hospital , Shizuoka, Japan
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