Impact of time to return of spontaneous circulation on neuroprotective effect of targeted temperature management at 33 or 36 degrees in comatose survivors of out-of hospital cardiac arrest

Introduction: Targeted temperature management (TTM) reduces neurologic injury from out-of-hospital cardiac arrest (OHCA). As the risk of neurologic injury increases with prolonged cardiac arrests, the benefit of TTM may depend upon cardiac arrest duration. We hypothesized that there is a time-dependent effect of TTM on neurologic outcomes from OHCA. Methods: Retrospective, observational study of the Toronto RescuNET Epistry-Cardiac Arrest database from 2007 to 2014. We included adult (>18) OHCA of presumed cardiac etiology that remained comatose (GCS<10) after a return of spontaneous circulation. We used multivariable logistic regression to determine the effect of TTM and the duration of cardiac arrest on good neurologic outcome (Modified Rankin Scale (mRS) 0-3) and survival to hospital discharge while controlling for other known predictors. Results: There were 1496 patients who met our inclusion criteria, of whom 981 (66%) received TTM. Of the patients who received TTM, 59% had a good neurologic outcome compared to 39% of patients who did not receive TTM (p< 0.001). After adjusting for the Utstein variables, use of TTM was associated with improved neurologic outcome (OR 1.60, 95% CI 1.10-2.32; p = 0.01) but not with survival to discharge (OR 1.23, 95% CI 0.90-1.67; p = 0.19). The impact of TTM on neurologic outcome was dependent on the duration of cardiac arrest (p<0.05) (Fig 1). Other significant predictors of good neurologic outcome were younger age, public location, initial shockable rhythm, and shorter duration of cardiac arrest (all p values < 0.05). A subgroup analysis found the use of TTM to be associated with neurologic outcome in both shockable (p = 0.01) and non-shockable rhythms (p = 0.04) but was not associated with survival to discharge in either group (p = 0.12 and p = 0.14 respectively). Conclusion: The use of TTM was associated with improved neurologic outcome at hospital discharge. Patients with prolonged durations of cardiac arrest benefited more from TTM.

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Survival and Neurologic Outcome of Different Time of Collapse to return of Spontaneous Circulation in Cardiac Arrest with Targeted Temperature Management: a Bayesian Network Meta-analysis

10.37766/inplasy2021.8.0027 ◽

2021 ◽

Author(s):

Jingwei Duan ◽

Jie Yu ◽

Qiangrong Zhai ◽

Qingbian Ma

Keyword(s):

Cardiac Arrest ◽

Bayesian Network ◽

Meta Analysis ◽

Spontaneous Circulation ◽

Targeted Temperature Management ◽

Neurologic Outcome ◽

Temperature Management ◽

Return Of Spontaneous Circulation

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Abstract 349: Target Temperature Management After Return of Spontaneous Circulation Did Not Ameliorate Mid-term (30 to 90-day) Neurological Improvement in Out-of-hospital Cardiac Arrest Patients

Circulation ◽

10.1161/circ.142.suppl_4.349 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Hiromichi Naito ◽

Takashi Yorifuji ◽

Tetsuya Yumoto ◽

Tsuyoshi Nojima ◽

Noritomo Fujisaki ◽

...

Keyword(s):

Logistic Regression ◽

Cardiac Arrest ◽

Regression Analysis ◽

Spontaneous Circulation ◽

Temperature Management ◽

Multivariable Logistic Regression Analysis ◽

Return Of Spontaneous Circulation ◽

Neurological Improvement ◽

Hospital Cardiac Arrest

Introduction: Mid/long-term outcomes of out-of-hospital cardiac arrest (OHCA) survivors have not been extensively studied. Targeted temperature management (TTM) after return of spontaneous circulation is one known therapeutic approach to ameliorate short-term neurological improvement of OHCA patients; however, the prognostic significance of TTM in the mid/long-term clinical setting have not been defined. Hypothesis: TTM would confer additional improvement of OHCA patients’ mid-term neurological outcomes. Methods: Retrospective study using the Japanese Association for Acute Medicine OHCA Registry (Jun 2014 - Dec 2017): a nationwide multicenter registry. Patients who did not survive 30 days after OHCA, those with missing 30-day Cerebral Performance Category (CPC) scores, and those < 18 years old were excluded. Primary endpoint was alteration of neurological function evaluated with 30-day and 90-day CPC. Association between application of TTM (33-36°C) and mid-term CPC alteration was evaluated. Multivariable logistic regression analysis was used for the primary outcome; results are expressed with odds ratio (OR) and 95% confidence interval (CI). Results: We included 2,905 in the analysis. Patient characteristics were: age: 67 [57 - 78] years old, male gender: 70.8%, witnessed collapse: 81.4%, dispatcher instruction for CPR: 51.6%, initial shockable rhythm: 67.0%, and estimated cardiac origin: 76.5%. TTM was applied to 1,352/2,905 (46.5%) patients. Thirty-day CPC values in surviving patients were: CPC 1: 1,155/2,905 (39.8%), CPC 2: 321/2,905 (11.1%), CPC 3: 497/2,905 (17.1%), and CPC 4: 932/2,905 (32.1%), respectively. Ninety-day CPC values were: CPC 1: 866/1,868 (46.4%), CPC 2: 154/1,868 (8.2%), CPC 3: 224/1,868 (12.0%), CPC 4: 392/1,868 (20.1%), and CPC 5: 232/1,868 (12.4%), respectively. Of 1,636 patients with 90-day survival, 28 (1.7%) demonstrated improved CPC at 90 days, whereas, 133 (8.1%) showed worsened CPC at 90 days compared with 30-day CPC, respectively. Multivariable logistic regression analysis revealed TTM did not result in favorable mid-term neurological changes (adjusted OR: 1.44, 95% CI: 0.48 - 4.31). Conclusions: TTM may not contribute to the beneficial effect on OHCA patients’ mid-term neurological changes.

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Inter-Hospital Transfer after Return of Spontaneous Circulation Shows no Correlation with Neurological Outcomes in Cardiac Arrest Patients Undergoing Targeted Temperature Management in Cardiac Arrest Centers

Journal of Clinical Medicine ◽

10.3390/jcm9061979 ◽

2020 ◽

Vol 9 (6) ◽

pp. 1979

Author(s):

Yoon Hee Choi ◽

Dong Hoon Lee ◽

Je Hyeok Oh ◽

Jin Hong Min ◽

Tae Chang Jang ◽

...

Keyword(s):

Cardiac Arrest ◽

Spontaneous Circulation ◽

Targeted Temperature Management ◽

Temperature Management ◽

Return Of Spontaneous Circulation ◽

Neurological Outcomes ◽

Neurologic Outcomes ◽

Hospital Transfer ◽

St Elevation ◽

Transferred Patients

This study evaluated whether inter-hospital transfer (IHT) after the return of spontaneous circulation (ROSC) was associated with poor neurological outcomes after 6 months in post-cardiac-arrest patients treated with targeted temperature management (TTM). We used data from the Korean Hypothermia Network prospective registry from November 2015 to December 2018. These out-of-hospital cardiac arrest (OHCA) patients had either received post-cardiac arrest syndrome (PCAS) care at the same hospital or had been transferred from another hospital after ROSC. The primary endpoint was the neurological outcome 6 months after cardiac arrest. Subgroup analyses were performed to determine differences in the time from ROSC to TTM induction according to the electrocardiography results after ROSC. We enrolled 1326 patients. There were no significant differences in neurological outcomes between the direct visit and IHT groups. In patients without ST elevation, the mean time to TTM was significantly shorter in the direct visit group than in the IHT group. IHT after achieving ROSC was not associated with neurologic outcomes after 6 months in post-OHCA patients treated with TTM, even though TTM induction was delayed in transferred patients.

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Abstract 14644: Impact of Time to Return of Spontaneous Circulation on Neuro-protective Effect of Target Temperature Management at 33 and 36 Degrees in Comatose Survivors of Out of Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.130.suppl_2.14644 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Jesper Kjaergaard ◽

Matilde Winther-Jensen ◽

Niklas Nielsen ◽

Anders åneman ◽

Wise P Matt ◽

...

Keyword(s):

Cardiac Arrest ◽

Neurological Outcome ◽

Spontaneous Circulation ◽

Temperature Management ◽

Target Temperature Management ◽

Significant Prognostic Factor ◽

Target Temperature ◽

Return Of Spontaneous Circulation ◽

Prolonged Time ◽

Hospital Cardiac Arrest

Introduction: Prolonged time to Return of Spontaneous Circulation (ttROSC) after Out of Hospital Cardiac Arrest (OHCA) has consistently been associated with adverse outcome by a plausible direct relation to severity of anoxic injury. Hypothesis: Target temperature management (TTM) is assumed effective against anoxic brain injury and we hypothesized that TTM at 33 degrees would be more beneficial with prolonged time to ROSC compared to 36 degrees. Methods: In a post hoc analysis of the TTM trial, which showed no overall benefit of targeting 33 °C over 36 in 939 patients (NEJM 2013), we investigated the relation of time to ROSC and mortality and neurological outcome as assessed by the Cerebral Performance Category (CPC) and Modified Ranking Scale (mRS) after 180 days. Results: Prolonged ttROSC was significantly and independently associated with increased mortality, p<0.001 (figure), with Hazard Ratio (HR) of 1.02 (95% CI 1.01-1.02, p<0.001) per minute increase and level of TTM did not modify this association, p interaction =0.85. In survivors prolonged ttROSC was associated with increased odds of surviving with an unfavorable neurological outcome for CPC (p=0.008 for CPC 3-4) and a similar trend, albeit not statistically significant was observed for mRS (p=0.17, mRS 4-5). Odds for unfavorable neurological outcome (CPC>2, mRS>3) was not modified by levels of TTM overall. Conclusion: Time to ROSC remains a significant prognostic factor in comatose patients resuscitated from OHCA with regards to risk of death and risk of adverse neurological outcome in survivors. TTM at 33 degrees offers no advantage over targeting 36 degrees with regards to mortality or neurological outcome in patients with prolonged time to ROSC. Figure: Mortality rates stratified by quartiles of tome to ROSC and by TTM level. Differences tested by log rank test in between TTM in strata

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Abstract 158: Association Between Initial Body Temperature and Neurologic Outcomes of Out-Of-Hospital Cardiac Arrest Undergoing Targeted Temperature Management

Circulation ◽

10.1161/circ.140.suppl_2.158 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Jong Hwan Kim ◽

Jeong Ho Park ◽

Sun Young Lee ◽

Sang Do Shin ◽

Jieun Pak ◽

...

Keyword(s):

Cardiac Arrest ◽

Body Temperature ◽

Spontaneous Circulation ◽

Targeted Temperature Management ◽

Temperature Management ◽

Target Temperature ◽

Multivariable Logistic Regression Model ◽

Neurologic Recovery ◽

Neurologic Outcomes ◽

Hospital Cardiac Arrest

Objectives: Targeted temperature management (TTM) is the core post-resuscitation care to minimize neurologic deficit after out-of-hospital cardiac arrest (OHCA). Uncontrolled body temperature of patients may reflect the thermoregulation ability which can be associated with neurologic damage during arrest. The aim of this study was to investigate the association between initial body temperature (BT) and neurologic outcomes in OHCA patients who underwent TTM. Methods: We used nationwide OHCA database from January 2016 to December 2017. Adult OHCA patients with presumed cardiac etiology who underwent TTM after return-of-spontaneous circulation (ROSC) were included. The main exposure was a BT at initiation of TTM which was categorized into 3 groups: low (-35.5°c), middle(35.6°c-37.4°c), and high BT (37.5°c-). The primary outcome was good neurologic outcome (cerebral performance categories (CPC) 1 or 2). Adjusted ratios (AORs) and 95% confidence intervals (CIs) were estimated to evaluate association between initial BT of TTM and outcome in multivariable logistic regression model. Stratified subgroup analyses were according to the target temperature of TTM (hypothermia vs normothermia). Results: Of a total of 744 patients, 208 (28.0%) patients were low initial BT group and 471 (63.3%) patients were normal initial BT group and 65 (8.7%) patients were high initial BT group. Good neurological recovery rate was 13.9% in low initial BT group, 41.8% in middle initial BT group and 36.9% in high initial BT group. The adjusted odds ratios for good neurologic recovery were 0.281 (95% confidence interval [CI] 0.17-0.47) in low BT group and 0.65 (95% CI 0.34-1.27) in high BT group compared with normal initial BT group. Similar results were also found regardless of target temperature of TTM. Conclusion: Low initial BT of TTM was associated with unfavorable neurologic recovery for OHCA patients who underwent TTM after ROSC.

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Abstract 346: Targeted Temperature Management is Associated with Improved Neurological Outcomes in Witnessed Out-of-hospital Cardiac Arrest Patients Who Achieve Early Return of Spontaneous Circulation

Circulation ◽

10.1161/circ.142.suppl_4.346 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Nobuyuki Enzan ◽

Ken-ichi Hiasa ◽

Kenzo Ichimura ◽

Masaaki Nishihara ◽

Takeshi Iyonaga ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score ◽

Propensity Score Matching ◽

Odds Ratio ◽

Spontaneous Circulation ◽

Temperature Management ◽

Return Of Spontaneous Circulation ◽

Neurological Outcomes ◽

Propensity Score Matching Analysis ◽

Hospital Cardiac Arrest

Background: Previous randomized controlled trials demonstrated the efficacy of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) patients with both shockable and non-shockable rhythm. Real-world evidence for TTM using large OHCA database are scarce, and no study has investigated the relationship between TTM and time-to-return of spontaneous circulation (ROSC). Methods: The Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. Patients with witnessed non-traumatic OHCA who had been resuscitated and were in a coma were included. Eligible patients were divided into two groups according to the use of TTM. The primary outcome was defined as a Cerebral Performance Categories (CPC) Scale 1-2 at 30 days after OHCA. The propensity score matching analysis was used. The cubic spline analysis of the odds ratio of CPC 1-2 for TTM use by time-to-ROSC was performed. Results: Out of 34,754 patients with OHCA, 5,261 patients were included. The mean age was 70.3 years, and 3,417 (65.0%) were male. CPC 1-2 was more frequently observed in the TTM group in propensity score matching analysis (15.1% vs. 8.5%; odds ratio 1.92; 95% confidence interval 1.04-3.53; P=0.037). The cubic spline analysis showed that TTM was associated with CPC 1-2 in witnessed OHCA patients, which did not reach statistical significance in patients with time-to-ROSC longer than 50 min. Conclusions: TTM was associated with better neurological outcomes in witnessed OHCA patients, especially when patients were resuscitated within 50 min after collapse.

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Targeted temperature management following third trimester cardiac arrest

Journal of Clinical Images and Medical Case Reports ◽

10.52768/2766-7820/1186 ◽

2021 ◽

Vol 2 (3) ◽

Author(s):

Sarah K Conrad ◽

◽

Erika Lutins ◽

Susan Lanni ◽

Nicole Karjane ◽

...

Keyword(s):

Cardiac Arrest ◽

Intensive Care ◽

Neonatal Intensive Care ◽

American Heart ◽

Heart Association ◽

Spontaneous Circulation ◽

Targeted Temperature Management ◽

Temperature Management ◽

Third Trimester ◽

Hospital Cardiac Arrest

Background: According to the American Heart Association (AHA), post-cardiac arrest use of targeted temperature management (TTM) can be considered for pregnant patients; however, data is lacking, particularly following fetal viability. Case: A 31 year old, female presented at 36 weeks gestation after an out-of-hospital cardiac arrest. Resuscitation resulted in return of spontaneous circulation (ROSC); however, the patient was unresponsive upon hospital arrival. She underwent TTM, was cooled and rewarmed without incident. She underwent cesarean delivery 36 hours after cardiac arrest. By time of discharge, she had full neurological recovery, with only amnesia surrounding the acute cardiac event. The neonate was discharged after a brief stay in the neonatal intensive care unit, having met discharge criteria. Conclusion: TTM should be considered post cardiac arrest, even in the third trimester. Keywords: Targeted temperature management; Cardiac arrest; Pregnancy. Abbreviations: AHA: American Heart Association; TTM: Targeted Temperature Management; ROSC: Return Of Spontaneous Circulation; EMS: Emergency Medical Services; ARCTIC: Advanced Resuscitation Cooling Therapeutics Intensive Care; NICU: Neonatal Intensive Care Unit; OHCA: Out of Hospital Cardiac Arrest.

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Abstract 19708: Pre-Hospital Initiation of Therapeutic Hypothermia Associated With Better Survival and Neurologic Outcome in a Broad Population of Patients in North Carolina

Circulation ◽

10.1161/circ.130.suppl_2.19708 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Meena P Rao ◽

Matthew Dupre ◽

Carolina Hansen ◽

Sarah Milford-Beland ◽

Lisa Monk ◽

...

Keyword(s):

North Carolina ◽

Cardiac Arrest ◽

Therapeutic Hypothermia ◽

Spontaneous Circulation ◽

Neurologic Outcome ◽

Temperature Management ◽

P Value ◽

Return Of Spontaneous Circulation ◽

Hospital Survival ◽

Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) has less than 10% hospital survival. While therapeutic hypothermia resulted in a 16%-24% improvement in neurologic outcome in patients with ventricular fibrillation (VF) in prior trials, recent trials have not shown benefit of pre-hospital initiation hypothermia or of hospital cooling to 33 vs 36 degrees. Methods: We studied patients who suffered OHCA in North Carolina from 2012-2013 captured in the CARES database as part of the Heart Rescue Project. To limit selection bias, we excluded patients without return of spontaneous circulation after arrest and without intubation in the field as they may have regained consciousness. Results: 847 patients were included in the analysis of pre-hospital hypothermia. The patients that received pre-hospital hypothermia had more bystander initiated CPR (p-value < 0.45). Pre-hospital hypothermia was associated with a significant increase in survival to hospital discharge (OR 1.55, 95% CI 1.03-2.32) and neurologic outcome at discharge (OR 1.56 95% CI 1.01-2.40). When looking at arrest types, the significant association was seen after VF arrest (figure). 537 patients survived to hospital admission and included in the analysis of in-hospital hypothermia. Patients who received hospital hypothermia were younger, had more VF, more witnessed arrest and more pre-hospital hypothermia. Hypothermia showed a non-significant trend toward better survival to discharge. Conclusions: The association between pre-hospital hypothermia after VF arrest and improved survival, in light of randomized data showing no effect, may be due to confounding or to a greater likelihood of in-hospital hypothermia in this group. The trend in better outcome using in-hospital hypothermia is consistent with a benefit from temperature management. These findings suggest the need for ongoing efforts to understand the value of hypothermia in context of other efforts to improve survival from cardiac arrest.

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Abstract 312: Abnormal Computerized Tomography of the Brain Immediately After Return of Spontaneous Circulation is Not Associated With Death Following Out of Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.138.suppl_2.312 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Paige Farley ◽

Francis X Guyette ◽

Adam Kessler ◽

Adam Robinett ◽

William Rushton ◽

...

Keyword(s):

Cardiac Arrest ◽

Computerized Tomography ◽

Imaging Modality ◽

Spontaneous Circulation ◽

Temperature Management ◽

Return Of Spontaneous Circulation ◽

Initial Rhythm ◽

Ct Head ◽

The Brain ◽

Hospital Cardiac Arrest

Study Objectives: Many post-resuscitation programs routinely utilize immediate computerized tomography of the brain (CT head) following return of spontaneous circulation (ROSC) to inform initiation of targeted temperature management (TTM) for out-of-hospital cardiac arrest (OHCA). We sought to compare the association of abnormal immediate CT head with clinical outcome. Methods: Included were consecutive adults with non-traumatic OHCA treated from 2010 to 2018 by two comprehensive post-resuscitation programs. We combined comparable, prospective OHCA registries of clinical and demographic data at each site with a retrospective, structured chart review to abstract results of CT head performed prior to TTM initiation. Using multivariable logistic regression, we evaluated the association between abnormal immediate CT head and death adjusting for age, sex, race, witnessed arrest, shockable initial rhythm, and site. Results: Among 172 patients with OHCA, characteristics were median age 60 years (IQR 50-69), male 62.7%, African-American 52.3%, witnessed arrest 85.4%, and shockable initial rhythm 31.3%. CT Head in these subjects was abnormal in 27.9% of cases, specifically demonstrating hypoxic edema in 22.0%. In adjusted models, death was associated with greater age (adjusted OR 1.03 95% CI 1.01-1.06), non-shockable initial rhythm (adjusted OR 3.82 95% CI 1.64-8.95), and longer total time pulseless (adjusted OR 1.02 95% CI 1.01-1.06). In contrast, hypoxic edema or other abnormal CT head readings were not associated with death. Conclusion: In this dual-site pilot investigation abnormal findings on immediate CT head following ROSC were not associated with death. Caution should be used when utilizing this imaging modality to inform treatment decisions following OHCA.

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