History and current use of mild therapeutic hypothermia after cardiac arrest.
ABSTRACT: In spite of many years of development and implementation of pre-hospital advanced life support programmes, the survival rate of out-of-hospital cardiac arrest (OHCA) used to be very poor. Neurologic injury from cerebral hypoxia is the most common cause of death in patients with OHCA. In the past two decades, post-resuscitation care has developed many new concepts aimed at improving the neurological outcome and survival rate of patients after cardiac arrest. Systematic post-cardiac arrest care after the return of spontaneous circulation, including induced mild therapeutic hypothermia (TH) in selected patients, is aimed at significantly improving rates of long-term neurologically intact survival. This review summarises the history and current knowledge in the field of mild TH after OHCA.
Project description:Mild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). International guidelines strongly support initiating TH for all eligible individuals presenting with OHCA; however, the timing of cooling initiation remains uncertain. This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA.The MEDLINE and Cochrane databases were searched from inception to October 2017. Inclusion criteria for full-text review included RCTs comparing pre-hospital TH with no pre-hospital TH after cardiac arrest, patients >?14 years of age with documented cardiac arrest from any rhythm, and outcome data that included survival to hospital discharge and temperature at hospital arrival. Results of retrieved studies were compared through meta-analysis using random effects modelling.A total of 10 trials comprising 4220 patients were included. There were no significant differences between the two arms for the primary outcome of neurological recovery (risk ratio [RR] 1.04, 95% CI 0.93-1.15) or the secondary outcome of survival to hospital discharge (RR 1.01, 95% CI 0.92-1.11). However, there was a significantly lower temperature at hospital arrival in patients receiving pre-hospital TH (mean difference -?0.83, 95% CI -?1.03 to -?0.63). Pre-hospital TH significantly increased the risk of re-arrest (RR 1.19, 95% CI 1.00 to 1.41). No survival differences were observed among subgroups of patients who received intra-arrest TH vs post-arrest TH or who had shockable vs non-shockable rhythms.Pre-hospital TH after OHCA effectively decreases body temperature at the time of hospital arrival. However, it does not improve rates of survival with good neurological outcome or overall survival and is associated with increased rates of re-arrest.
Project description:Survival from out-of-hospital cardiac arrest (OHCA) has remained low despite advances in resuscitation science. Hospital-based extra-corporeal cardiopulmonary resuscitation (ECPR) is a novel use of an established technology that provides greater blood flow and oxygen delivery during cardiac arrest than closed chest compressions. Hospital-based ECPR is currently offered to selected OHCA patients in specialized centres. The interval between collapse and restoration of circulation is inversely associated with good clinical outcomes after ECPR. Pre-hospital delivery of ECPR concurrent with conventional resuscitation is one approach to shortening this interval and improving outcomes after OHCA. This article examines the background and rationale for pre-hospital ECPR; summarises the findings of a literature search for published evidence; and considers candidate selection, logistics, and complications for this complex intervention.
Project description:Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH.This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC.105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0-32.3)min and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (?10min, 11-20min, 21-30min, >30min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20min, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm.Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime >20min.
Project description:BACKGROUND:Therapeutic Hypothermia (TH) is a standard of care after out-of-hospital cardiac arrest (OHCA). Previous reports failed to prove a significant benefit for survival or neurological outcomes. We examined whether the proper selection of patients would enhance treatment efficacy. METHOD:We conducted a retrospective cohort study. Data was collected from January 2000 and August 2018. Patients were enrolled after OHCA and classified into two groups, patients treated with TH and patients who were not treated with TH. RESULTS:A total of 92 patients were included in the study. 57 (63%) patients were in the TH Group and 34 (37%) in the Non-TH group. There was no statistical difference in favorable neurological outcomes between the groups. Patients presenting with ventricular fibrillation had a higher 1-year survival rate from TH, while patients with asystole were found to benefit only if they were younger than 65 years (p < .007, p < .02, respectively). CONCLUSION:Therapeutic Hypothermia patients failed to demonstrate a significant benefit in terms of improved neurological outcomes. Patients treated with TH following ventricular fibrillation experienced the most benefit in terms of 1-year survival, while patients who had suffered from asystole experienced a modest benefit only if they were younger than 65 years of age. Guidelines should address age and primary arrhythmia for proper treatment selection.
Project description:To assess the evidence and make evidence-based recommendations for acute interventions to reduce brain injury in adult patients who are comatose after successful cardiopulmonary resuscitation.Published literature from 1966 to August 29, 2016, was reviewed with evidence-based classification of relevant articles.For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32-34°C for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (36°C for 24 hours, followed by 8 hours of rewarming to 37°C, and temperature maintenance below 37.5°C until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed.
Project description:Therapeutic hypothermia (TH) improves outcomes in comatose survivors of cardiac arrest. Few hospitals have protocol-driven plans that include TH. We implemented a series of process interventions designed to increase TH use and improve outcomes in patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA).Linked interventions including a TH order sheet, verbal and written feedback to individual providers, an educational program, TH "kit" and on-call consultants to assist with patient care and hypothermia induction were implemented between January 1, 2005 and December 31, 2007 in a large, university-affiliated, tertiary care center. We then completed a retrospective review of all patients treated for cardiac arrest during the study period. Descriptive statistics, chi-squared analyses, or Fisher's exact test were used as appropriate. A p value <0.05 was considered significant. 135 OHCA patients and 106 IHCA patients were eligible for post-arrest care. TH use increased each year in the OHCA group (from 6% to 65% to 76%; p<0.001) and IHCA group (from 0% to 36% to 53%; p=.02). A good outcome was achieved in 21% and 8% of comatose patients with OHCA and IHCA, respectively. Patients with OHCA and ventricular dysrhythmia were more likely to have a good outcome with TH treatment than without it (good outcome in 57% vs. 8%; p=.005).Implementing a series of aggressive interventions increased appropriate TH use and was associated with improved outcomes in our facility.
Project description:<h4>Objective</h4>High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry.<h4>Methods</h4>We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months.<h4>Results</h4>Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours.<h4>Conclusion</h4>The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.
Project description:Guidelines recommend mild therapeutic hypothermia (MTH) for survivors of out-of-hospital cardiac arrest (OHCA). However, there is little literature demonstrating a survival benefit. We performed a meta-analysis of randomized controlled trials (RCTs) assessing the efficacy of MTH in patients successfully resuscitated from OHCA.Electronic databases were searched for RCT involving MTH in survivors of OHCA, and the results were put through a meta-analysis. The primary endpoint was all-cause mortality, and the secondary endpoint was favorable neurological function. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using the Mantel-Haenszel method. A fixed-effect model was used and, if heterogeneity (I2 ) was >40, effects were analyzed using a random model.Six RCT (n = 1400 patients) were included. Overall survival was 50.7%, and favorable neurological recovery was 45.5%. Pooled data demonstrated no significant all-cause mortality (OR, 0.81; 95% CI 0.55-1.21) or neurological recovery (OR, 0.77; 95% CI 0.47-1.24). No evidence of publication bias was observed.This meta-analysis demonstrated that MTH did not confer benefit on overall survival rate and neurological recovery in patients resuscitated from OHCA.
Project description:<h4>Objective</h4>This study assessed the ability of the Acute Physiologic and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, and out-of-hospital cardiac arrest (OHCA) score to predict the outcome of OHCA patients who underwent therapeutic hypothermia (TH).<h4>Methods</h4>This study included OHCA patients treated with TH between January 2010 and December 2013. The APACHE II score, SAPS II, and SOFA score were calculated at the time of admission and 24 h and 48 h after intensive care unit admission. The OHCA score was calculated at the time of admission. The area under the curve (AUC) of the receiver operating characteristic curve and logistic regression analysis were used to evaluate outcome predictability.<h4>Results</h4>Data from a total of 173 patients were included in the analysis. The APACHE II score at 0 h and 48 h, SAPS II at 48 h, and OHCA score had moderate discrimination for mortality (AUC: 0.715, 0.750, 0.720, 0.740). For neurologic outcomes, the APACHE II score at 0 h and 48 h, SAPS II at 0 h and 48 h, and OHCA score showed moderate discrimination (AUC: 0.752, 0.738, 0.771, 0.771, 0.764). The APACHE II score, SAPS II and SOFA score at various time points, in addition to the OHCA score, were independent predictors of mortality and a poor neurologic outcome.<h4>Conclusions</h4>The APACHE II score, SAPS II, SOFA score, and OHCA score have different capabilities in discriminating and estimating hospital mortality and neurologic outcomes. The OHCA score, APACHE II score and SAPS II at time zero and 48 h offer moderate predictive accuracy. Other scores at 0 h and 48 h, except for the SOFA score, are independently associated with 30-day mortality and poor cerebral performance.
Project description:Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms.We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH.Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.