Hypothermic modulation of anoxic brain injury in adult survivors of cardiac arrest: a review of the literature and an algorithm for emergency physicians

ABSTRACT Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.

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The use of induced hypothermia after cardiac arrest: a survey of Canadian emergency physicians

CJEM ◽

10.1017/s1481803500009830 ◽

2008 ◽

Vol 10 (02) ◽

pp. 125-130 ◽

Cited By ~ 18

Author(s):

Joel Kennedy ◽

Robert S. Green ◽

Robert Stenstrom ◽

Keyword(s):

Cardiac Arrest ◽

Clinical Practice ◽

Patient Outcomes ◽

Odds Ratio ◽

Mild Hypothermia ◽

Induced Hypothermia ◽

Emergency Physicians ◽

Institutional Policies ◽

Unadjusted Odds Ratio ◽

Canadian Association

ABSTRACTObjective:Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.Methods:An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.Results:Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%–53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%–47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3–20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.Conclusion:Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.

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TRENDS, PREDICTORS AND OUTCOMES AFTER UTILIZATION OF TARGETED TEMPERATURE MANAGEMENT IN CARDIAC ARREST PATIENTS WITH ANOXIC BRAIN INJURY

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(20)31102-5 ◽

2020 ◽

Vol 75 (11) ◽

pp. 475

Author(s):

Kinjan Patel ◽

Bilal Munir ◽

Muhammad U. Khan ◽

Safi Khan ◽

Mohammed Osman ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Targeted Temperature Management ◽

Temperature Management ◽

Anoxic Brain Injury

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Trends, Predictors and Outcomes After Utilization of Targeted Temperature Management in Cardiac Arrest Patients With Anoxic Brain Injury

The American Journal of the Medical Sciences ◽

10.1016/j.amjms.2020.05.025 ◽

2020 ◽

Vol 360 (4) ◽

pp. 363-371

Author(s):

Muhammad Zia Khan ◽

Muhammad U. Khan ◽

Kinjan Patel ◽

Safi U. Khan ◽

Shahul Valavoor ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Targeted Temperature Management ◽

Temperature Management ◽

Anoxic Brain Injury

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THE EFFECT OF INDUCED HYPOTHERMIA ON CEREBRAL OXYGEN AND LACTATE METABOLISM FOLLOWING ANOXIC BRAIN INJURY

Critical Care Medicine ◽

10.1097/00003246-199901001-00092 ◽

1999 ◽

Vol 27 (Supplement) ◽

pp. 53A

Author(s):

Stephen Bernard ◽

Tim Gray ◽

Michael Buist ◽

Bruce Jones ◽

William Silvester ◽

...

Keyword(s):

Brain Injury ◽

Induced Hypothermia ◽

Cerebral Oxygen ◽

Lactate Metabolism ◽

Anoxic Brain Injury

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Cerebral autoregulation in anoxic brain injury patients treated with targeted temperature management

Journal of Intensive Care ◽

10.1186/s40560-021-00579-z ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Ilaria Alice Crippa ◽

Jean-Louis Vincent ◽

Federica Zama Cavicchi ◽

Selene Pozzebon ◽

Filippo Annoni ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Body Temperature ◽

Hospital Discharge ◽

Core Body Temperature ◽

Targeted Temperature Management ◽

Temperature Management ◽

Anoxic Brain Injury ◽

Shockable Rhythm ◽

Core Body

Abstract Background Little is known about the prevalence of altered CAR in anoxic brain injury and the association with patients’ outcome. We aimed at investigating CAR in cardiac arrest survivors treated by targeted temperature management and its association to outcome. Methods Retrospective analysis of prospectively collected data. Inclusion criteria: adult cardiac arrest survivors treated by targeted temperature management (TTM). Exclusion criteria: trauma; sepsis, intoxication; acute intra-cranial disease; history of supra-aortic vascular disease; severe hemodynamic instability; cardiac output mechanical support; arterial carbon dioxide partial pressure (PaCO2) > 60 mmHg; arrhythmias; lack of acoustic window. Middle cerebral artery flow velocitiy (FV) was assessed by transcranial Doppler (TCD) once during hypothermia (HT) and once during normothermia (NT). FV and blood pressure (BP) were recorded simultaneously and Mxa calculated (MATLAB). Mxa is the Pearson correlation coefficient between FV and BP. Mxa > 0.3 defined altered CAR. Survival was assessed at hospital discharge. Cerebral Performance Category (CPC) 3–5 assessed 3 months after CA defined unfavorable neurological outcome (UO). Results We included 50 patients (Jan 2015–Dec 2018). All patients had out-of-hospital cardiac arrest, 24 (48%) had initial shockable rhythm. Time to return of spontaneous circulation was 20 [10–35] min. HT (core body temperature 33.7 [33.2–34] °C) lasted for 24 [23–28] h, followed by rewarming and NT (core body temperature: 36.9 [36.6–37.4] °C). Thirty-one (62%) patients did not survive at hospital discharge and 36 (72%) had UO. Mxa was lower during HT than during NT (0.33 [0.11–0.58] vs. 0.58 [0.30–0.83]; p = 0.03). During HT, Mxa did not differ between outcome groups. During NT, Mxa was higher in patients with UO than others (0.63 [0.43–0.83] vs. 0.31 [− 0.01–0.67]; p = 0.03). Mxa differed among CPC values at NT (p = 0.03). Specifically, CPC 2 group had lower Mxa than CPC 3 and 5 groups. At multivariate analysis, initial non-shockable rhythm, high Mxa during NT and highly malignant electroencephalography pattern (HMp) were associated with in-hospital mortality; high Mxa during NT and HMp were associated with UO. Conclusions CAR is frequently altered in cardiac arrest survivors treated by TTM. Altered CAR during normothermia was independently associated with poor outcome.

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How can neurological outcomes be predicted in comatose pediatric patients after out-of-hospital cardiac arrest?

Clinical and Experimental Pediatrics ◽

10.3345/kjp.2019.00941 ◽

2020 ◽

Vol 63 (5) ◽

pp. 164-170 ◽

Cited By ~ 1

Author(s):

Hyo Jeong Kim

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Neurological Examination ◽

Pediatric Patients ◽

Blood Biomarkers ◽

Neurological Outcomes ◽

Multiple Factors ◽

Response Recovery ◽

Hospital Cardiac Arrest ◽

Unmeasured Confounders

The prognosis of patients who are comatose after resuscitation remains uncertain. The accurate prediction of neurological outcome is important for management decisions and counseling. A neurological examination is an important factor for prognostication, but widely used sedatives alter the neurological examination and delay the response recovery. Additional studies including electroencephalography, somatosensory-evoked potentials, brain imaging, and blood biomarkers are useful for evaluating the extent of brain injury. This review aimed to assess the usefulness of and provide practical prognostic strategy for pediatric postresuscitation patients. The principles of prognostication are that the assessment should be delayed until at least 72 hours after cardiac arrest and the assessment should be multimodal. Furthermore, multiple factors including unmeasured confounders in individual patients should be considered when applying the prognostication strategy.

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P049: Post-intubation sedation in the emergency department: a survey of national practice patterns

CJEM ◽

10.1017/cem.2019.240 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S80

Author(s):

S. Freeman ◽

M. Columbus ◽

T. Nguyen ◽

S. Mal ◽

J. Yan

Keyword(s):

Emergency Department ◽

Cardiac Arrest ◽

Respiratory Failure ◽

Improve Patient Safety ◽

Teaching Hospitals ◽

Emergency Physicians ◽

Cross Sectional ◽

Canadian Association ◽

Clinical Scenarios ◽

Post Intubation

Introduction: Endotracheal intubation (ETI) is a lifesaving procedure commonly performed by emergency department (ED) physicians that may lead to patient discomfort or adverse events (e.g., unintended extubation) if sedation is inadequate. No ED-based sedation guidelines currently exist, so individual practice varies widely. This study's objective was to describe the self-reported post-ETI sedation practice of Canadian adult ED physicians. Methods: An anonymous, cross-sectional, web-based survey featuring 7 common ED scenarios requiring ETI was distributed to adult ED physician members of the Canadian Association of Emergency Physicians (CAEP). Scenarios included post-cardiac arrest, hypercapnic and hypoxic respiratory failure, status epilepticus, polytrauma, traumatic brain injury, and toxicology. Participants indicated first and second choice of sedative medication following ETI, as well as bolus vs. infusion administration in each scenario. Data was presented by descriptive statistics. Results: 207 (response rate 16.8%) ED physicians responded to the survey. Emergency medicine training of respondents included CCFP-EM (47.0%), FRCPC (35.8%), and CCFP (13.9%). 51.0% of respondents work primarily in academic/teaching hospitals and 40.4% work in community teaching hospitals. On average, responding physicians report providing care for 4.9 ± 6.8 (mean ± SD) intubated adult patients per month for varying durations (39.2% for 1–2 hours, 27.8% for 2–4 hours, and 22.7% for ≤1 hour). Combining all clinical scenarios, propofol was the most frequently used medication for post-ETI sedation (38.0% of all responses) and was the most frequently used agent except for the post-cardiac arrest, polytrauma, and hypercapnic respiratory failure scenarios. Ketamine was used second most frequently (28.2%), with midazolam being third most common (14.5%). Post-ETI sedation was provided by > 98% of physicians in all situations except the post-cardiac arrest (26.1% indicating no sedation) and toxicology (15.5% indicating no sedation) scenarios. Sedation was provided by infusion in 74.6% of cases and bolus in 25.4%. Conclusion: Significant practice variability with respect to post-ETI sedation exists amongst Canadian emergency physicians. Future quality improvement studies should examine sedation provided in real clinical scenarios with a goal of establishing best sedation practices to improve patient safety and quality of care.

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