Turn-to-Shockable Rhythm Has Comparable Neurologic Outcomes to Initial Shockable Rhythm in Out-of-Hospital Cardiac Arrest Patients Who Underwent Targeted Temperature Management

Abstract Background: Given the morphological characteristics of schistocytes, thrombotic microangiopathy (TMA) score can be beneficial as it can be quickly and serially measured without additional effort or costs. This study aimed to investigate whether the serial TMA scores until 48 h post admission are associated with clinical outcomes in patients undergoing targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). Methods:We retrospectively evaluated a cohort of 185 patients using a prospective registry. We analyzed the TMA score at admission and after 12, 24, and 48 hours. The primary outcome measures were poor neurologic outcome at discharge and 30-day mortality. Results:Increased TMA scores at all measured time points were independent predictors of poor neurologic outcomes and 30-day mortality, with the TMA score at time-12 showing the strongest correlation (OR, 3.008; 95% CI, 1.707–5.3; p=0.001 and HR, 1.517; 95% CI, 1.196–1.925; p=0.001.Specifically, TMA score ≥2 at time-12 was closely associated with increased predictability of poor neurologic outcome (OR, 6.302; 95% CI: 2.841–13.976; p<0.001) and 30-day mortality (HR, 2.656; 95% CI: 1.675–4.211; p<0.001).Conclusions: Increased TMA scores predicted the neurologic outcome and 30-day mortalityin patients undergoing TTM after OHCA. In addition to the benefit of being quickly and serially measured by using an automated hematology analyzer without additional effort or costs, this finding indicates that the TMA score may be a helpful tool for rapid risk stratification and identification of the need for intensive care in patients with ROSC after OHCA.

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Abstract 13761: Does Targeted Temperature Management Modify the Association Between Increasing Epinephrine Dose and Survival Outcomes Following Out-of-Hospital Cardiac Arrest?

Circulation ◽

10.1161/circ.144.suppl_2.13761 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Betty Yang ◽

Natalie Bulger ◽

Richard Chocron ◽

Catherine Counts ◽

Christopher Drucker ◽

...

Keyword(s):

Cardiac Arrest ◽

Cerebral Performance Category ◽

Neurological Status ◽

Targeted Temperature Management ◽

Temperature Management ◽

Shockable Rhythm ◽

Epinephrine Dose ◽

The Relationship ◽

Dose Dependent ◽

Hospital Cardiac Arrest

Introduction: Epinephrine (EPI) improves return of circulation after out of hospital cardiac arrest (OHCA). These beneficial cardiac effects are not accompanied by improved neurological survival possibly due to EPI induced microvascular effects and critical brain ischemia. We hypothesized that these dose-dependent adverse EPI effects may be mitigated by targeted temperature management (TTM) such that the relative benefit of TTM is greater at higher EPI doses. Methods: This was a retrospective cohort study of adult non-traumatic OHCA patients in Seattle and King County, Washington from 2008-2018, who were unconscious at hospital admission. We used logistic regression to assess the relationship among EPI dose, TTM, and survival to hospital discharge, and survival with favorable neurological status (Cerebral Performance Category (CPC) 1 or 2). The model evaluated whether TTM modified the association of increasing EPI dose using an interaction term between TTM and EPI dose. Results were stratified by initial shockable vs non-shockable rhythm. Results: Of 5254 eligible patients, the median EPI dose was 2.0 mg (IQR 1.0 - 3.0); 3052 (58%) received TTM. In all, 2177 (41%) survived to discharge, and 1889 (36%) survived with CPC 1-2. Increasing dose of EPI was associated with a decreasing likelihood of survival (OR 0.58, [95% CI 0.55-0.61] for each additional mg of EPI) and CPC 1-2 (OR 0.56, [0.53-0.59]). The dose-dependent EPI association was modified by TTM. After adjustment for Utstein covariates, for each additional mg of EPI, TTM was associated with a relative stepwise improvement in odds of survival (interaction OR 1.35, [1.23, 1.49]) and CPC 1-2 (OR 1.34, [1.21, 1.50]) (Figure). This interaction was consistent among shockable and non-shockable OHCA (Figure). Conclusions: We observed an interaction between TTM and EPI dose such that the beneficial association of TTM increased with increasing EPI dose, suggesting TTM may attenuate the adverse effects of higher dose EPI.

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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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Editor’s Choice-Effects of targeted temperature management on mortality and neurological outcome: A systematic review and meta-analysis

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872617744353 ◽

2017 ◽

Vol 7 (5) ◽

pp. 467-477 ◽

Cited By ~ 6

Author(s):

Dylan Stanger ◽

Vesna Mihajlovic ◽

Joel Singer ◽

Sameer Desai ◽

Rami El-Sayegh ◽

...

Keyword(s):

Cardiac Arrest ◽

Neurological Outcome ◽

Adult Survivors ◽

Targeted Temperature Management ◽

Temperature Management ◽

Shockable Rhythm ◽

Poor Neurological Outcome ◽

Meta Analyses ◽

Hospital Cardiac Arrest ◽

Quality Evidence

Aims: The purpose of this study was to conduct a systematic review, and where applicable meta-analyses, examining the evidence underpinning the use of targeted temperature management following resuscitation from cardiac arrest. Methods and results: Multiple databases were searched for publications between January 2000–February 2016. Nine Population, Intervention, Comparison, Outcome questions were developed and meta-analyses were performed when appropriate. Reviewers extracted study data and performed quality assessments using Grading of Recommendations, Assessment, Development and Evaluation methodology, the Cochrane Risk Bias Tool, and the National Institute of Health Study Quality Assessment Tool. The primary outcomes for each Population, Intervention, Comparison, Outcome question were mortality and poor neurological outcome. Overall, low quality evidence demonstrated that targeted temperature management at 32–36°C, compared to no targeted temperature management, decreased mortality (risk ratio 0.76, 95% confidence interval 0.61–0.92) and poor neurological outcome (risk ratio 0.73, 95% confidence interval 0.60–0.88) amongst adult survivors of out-of-hospital cardiac arrest with an initial shockable rhythm. Targeted temperature management use did not benefit survivors of in-hospital cardiac arrest nor out-of-hospital cardiac arrest survivors with a non-shockable rhythm. Moderate quality evidence demonstrated no benefit of pre-hospital targeted temperature management initiation. Low quality evidence showed no difference between endovascular versus surface cooling targeted temperature management systems, nor any benefit of adding feedback control to targeted temperature management systems. Low quality evidence suggested that targeted temperature management be maintained for 18–24 h. Conclusions: Low quality evidence supports the in-hospital initiation and maintenance of targeted temperature management at 32–36°C amongst adult survivors of out-of-hospital cardiac arrest with an initial shockable rhythm for 18–24 h. The effects of targeted temperature management on other populations, the optimal rate and method of cooling and rewarming, and effects of fever require further study.

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