Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

[Involuntary Psychiatric Hospitalizations: From request to a call center to hospitalization]

BACKGROUND

Involuntary psychiatric hospitalization (IPH) is a heavy and complex psychiatric exception measure. In the Seine-Saint-Denis department (low medical density), the evaluation of the patient in psychiatric decompensation is the responsibility of the out-of-hours general practitioners (GP) mandated by the call center. Their feeling is the non-achievement of the procedure once the patient arrives at the emergency room. We aimed to evaluate the outcome of patients following a request for IPH from these GP.

METHODS

We conducted a retrospective study based on all requests for IPH received during 2016 at the Seine-Saint-Denis emergency medical call center. The characteristics of the call and the patient, as well as the decisions of the regulator and the GP were collected. The decision of hospitalization in the emergency room was sought for patients referred for IPH.

RESULTS

Of the 7541 calls for decompensation, 539 were for an IPH. These calls occurred during non-working hours in 55 % of cases. A GP was involved in more than two-thirds of the cases and requested an IPH for 240/304 (79 %) patients. Patients were male in 56 % of cases with an average age of 40 (±16) years. IPH was confirmed for 132 (61 %) patients. This rate did not differ from the 65 % reported in the literature (Z-test, P=0.26). Voluntary hospitalization was performed for 37 (17 %) other patients.

DISCUSSION

The IPH rate for patients referred by GP mandated by the call center was comparable to that following the requests of the attending physicians, validating their intervention in this critical context.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

Corrélation entre la qualité de la réponse aux appels d’un Samu-Centre 15 et les effectifs d’assistants de régulation médicale — Étude QRAARM

Introduction : Le taux d’occupation des lignes téléphoniques d’un Samu-Centre 15 conditionne la fluidité de la gestion des appels et donc sa capacité de répondre à l’urgence. La disponibilité des assistants de régulation médicale (ARM) et des médecins régulateurs est déterminante. Nous nous sommes interrogés sur l’impact du nombre d’ARM sur la prise en charge des appels d’un Samu-Centre 15.

Méthodes : Le taux d’appels raccrochés (par l’appelant) après 15 secondes a été retenu comme critère de jugement principal. Il a été analysé en fonction de l’effectif « réel » d’ARM. L’effectif théorique d’ARM a été pris comme référence. Deux analyses ont été réalisées, la première portant sur 672 périodes d’un quart d’heure de la semaine 51 de l’année 2016 (en période d’épidémie de grippe) et la seconde sur 3 624 périodes d’une heure sur les cinq premiers mois de l’année 2017.

Résultats : Sur la première période, le nombre médian d’appels raccrochés après 15 secondes était de 1 (0–3) par quart d’heure. Il variait de 0 (0–1) à 3 (1–5) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001). Sur la seconde période, le nombre médian d’appels raccrochés était de 4 (1–8) par heure. Il variait de 2 (1–6) à 10 (6–16) selon l’effectif d’ARM auquel il était parfaitement inversement corrélé (p < 0,001).

Conclusion : Le taux d’appels raccrochés après 15 secondes était parfaitement corrélé à l’effectif (plus précisément au sous-effectif) d’ARM. Sur une année, le nombre estimé d’appels perdus ainsi était proche de 50 000 ! Prendre en considération l’effectif des ARM est une nécessité absolue.