Abstract 259: Outcomes of Targeted Temperature Management in Patients with Out-of-hospital Refractory Ventricular Fibrillation/ventricular Tachycardia Cardiac Arrest

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Kellen Albrecht ◽  
Jason Bartos ◽  
Demetris Yannopoulos
Keyword(s):  
Cardiac Arrest ◽  
Brain Death ◽  
Initial Temperature ◽  
Bleeding Risk ◽  
Targeted Temperature Management ◽  
Adult Patients ◽  
Temperature Management ◽  
Passive Cooling ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
The Impact

Background: Current guidelines recommend use of targeted temperature management (TTM) with goal between 32 and 36°C for all comatose adult patients with ROSC after cardiac arrest. However, refractory cardiac arrest with prolonged hypoperfusion, may cause passive cooling below goal temperature. The impact of this passive cooling and subsequent cooling strategies remains unknown. This study aims to describe the association between passive intra-arrest cooling and survival in patients suffering refractory VF/VT cardiac arrest treated with the University of Minnesota extracorporeal cardiopulmonary resuscitation (ECPR) protocol. Methods: Between December 2015 and October 2019, consecutive adult patients with refractory VF/VT arrest requiring ongoing CPR were transported by EMS to the CCL where ECPR, coronary angiography, and PCI were performed, as appropriate. TTM was initiated with goal temperature of 34°C unless clinically significant bleeding occurred, where a goal of 36°C was used. Patient and arrest characteristics, temperature data, and survival were collected retrospectively. Results: Data was gathered for 153 consecutive patients transferred for ECPR; 12 were excluded due to death in CCL prior to TTM. Of the remaining patients, 63 (41%) survived to discharge, where 55 (36%) had CPC scores of 1-2. Among deceased patients, 25 died from acute brain death while 47 died from other causes. Patients with CPC 1-2 had an initial temperature of 34.1°C versus 32.7°C in patients developing acute brain death (p=0.002). Survivors had shorter (p=0.0001) CPR time (52 minutes) versus deceased patients (65 minutes). If the initial temperature was below goal, patients were actively warmed to goal due to bleeding risk with ECPR. Survival to hospital discharge with CPC 1-2 was associated with lower peak warming rate compared with acute brain death (0.37°C/hr vs 0.69°C/hr; p=0.014) Conclusions: Survivors with CPC 1-2 after refractory VF/VT cardiac arrest and ECPR have preserved initial temperatures compared to more severe passive cooling in patients with acute brain death. This may be due to shorter duration of CPR. However, patients with acute brain death were noted to have higher peak rate of rewarming during TTM.

Targeted temperature management in patients undergoing extracorporeal life support after out-of-hospital cardiac arrest: an EURO-ELSO 2018 annual conference survey

Perfusion ◽  
2019 ◽  
Vol 34 (8) ◽  
pp. 714-716
Author(s):  
Caroline Rolfes ◽  
Ralf M Muellenbach ◽  
Philipp M Lepper ◽  
Tobias Spangenberg ◽  
Justyna Swol ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Bleeding Risk ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Annual Conference ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hospital Cardiac Arrest

Targeted temperature management and extracorporeal life support, particularly extracorporeal membrane oxygenation in patients undergoing cardiopulmonary resuscitation, represent outcome-enhancing strategies for patients following in- and out-of-hospital cardiac arrest. Although targeted temperature management with hypothermia between 32°C and 34°C and extracorporeal cardiopulmonary resuscitation bear separate potentials to improve outcome after out-of-hospital cardiac arrest, each is associated with bleeding risk and risk of infection. Whether the combination imposes excessive risk on patients is, however, unknown.

Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)?

2021 ◽  
pp. 088506662110189
Author(s):  
Merry Huang ◽  
Aaron Shoskes ◽  
Migdady Ibrahim ◽  
Moein Amin ◽  
Leen Hasan ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Neurological Outcome ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Survival Outcomes ◽  
Pool Data ◽  
Good Neurological Outcome ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Over Time

Purpose: Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. Methods: We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. Results: We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR ( P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) ( P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. Conclusions: Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.

Abstract 18656: The Effect of Targeted Temperature Management is Dependent Upon the Duration of Out-of-hospital Cardiac Arrest

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Ian R Drennan ◽  
Steve Lin ◽  
Kevin E Thorpe ◽  
Jason E Buick ◽  
Sheldon Cheskes ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Spontaneous Circulation ◽  
Targeted Temperature Management ◽  
Neurologic Outcome ◽  
Temperature Management ◽  
Neurologic Injury ◽  
Good Neurologic Outcome ◽  
The Impact ◽  
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.

scholarly journals Impact of rewarming rate on interleukin-6 levels in patients with shockable cardiac arrest receiving targeted temperature management at 33 °C: the ISOCRATE pilot randomized controlled trial

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Jean-Baptiste Lascarrou ◽  
Elie Guichard ◽  
Jean Reignier ◽  
Amélie Le Gouge ◽  
Caroline Pouplet ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Cardiac Arrest ◽  
Interleukin 6 ◽  
Controlled Trial ◽  
Cerebral Performance Category ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Randomized Controlled ◽  
Significant Difference ◽  
The Impact

Abstract Purpose While targeted temperature management (TTM) has been recommended in patients with shockable cardiac arrest (CA) and suggested in patients with non-shockable rhythms, few data exist regarding the impact of the rewarming rate on systemic inflammation. We compared serum levels of the proinflammatory cytokine interleukin-6 (IL6) measured with two rewarming rates after TTM at 33 °C in patients with shockable out-of-hospital cardiac arrest (OHCA). Methods ISOCRATE was a single-center randomized controlled trial comparing rewarming at 0.50 °C/h versus 0.25 °C/h in patients coma after shockable OHCA in 2016–2020. The primary outcome was serum IL6 level 24–48 h after reaching 33 °C. Secondary outcomes included the day-90 Cerebral Performance Category (CPC) and the 48-h serum neurofilament light-chain (NF-L) level. Results We randomized 50 patients. The median IL6 area-under-the-curve was similar between the two groups (12,389 [7256–37,200] vs. 8859 [6825–18,088] pg/mL h; P = 0.55). No significant difference was noted in proportions of patients with favorable day-90 CPC scores (13/25 patients at 0.25 °C/h (52.0%; 95% CI 31.3–72.2%) and 13/25 patients at 0.50 °C/h (52.0%; 95% CI 31.3–72.2%; P = 0.99)). Median NF-L levels were not significantly different between the 0.25 °C/h and 0.50 °C/h groups (76.0 pg mL, [25.5–3074.0] vs. 192 pg mL, [33.6–4199.0]; P = 0.43; respectively). Conclusion In our RCT, rewarming from 33 °C at 0.25 °C/h, compared to 0.50 °C/h, did not decrease the serum IL6 level after shockable CA. Further RCTs are needed to better define the optimal TTM strategy for patients with CA. Trial registration ClinicalTrials.gov, NCT02555254. Registered September 14, 2015. Take-Home Message: Rewarming at a rate of 0.25 °C/h, compared to 0.50 °C, did not result in lower serum IL6 levels after achievement of hypothermia at 33 °C in patients who remained comatose after shockable cardiac arrest. No associations were found between the slower rewarming rate and day-90 functional outcomes or mortality. 140-character Tweet: Rewarming at 0.25 °C versus 0.50 °C did not decrease serum IL6 levels after hypothermia at 33 °C in patients comatose after shockable cardiac arrest.

scholarly journals Pre Versus Post Implementation of a Pharmacologic Antishivering Protocol During Targeted Temperature Management Following Cardiac Arrest

2021 ◽  
Author(s):  
Calvin Huynh ◽  
Jevons Lui ◽  
Vala Behbahani ◽  
Ashley Thompson Quan ◽  
Amanda Morris ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Body Temperature ◽  
Medical Center ◽  
Academic Medical Center ◽  
Spontaneous Circulation ◽  
Neuromuscular Blocking ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Neurologic Outcomes ◽  
The Impact

Abstract Background Targeted temperature management (TTM) is endorsed by various guidelines to improve neurologic outcomes following cardiac arrest. Shivering, a consequence of hypothermia, can counteract the benefits of TTM. Despite its frequent occurrence, consensus guidelines provide minimal guidance on the management of shivering. The purpose of this study was to evaluate the impact of a pharmacologic antishivering protocol in patients undergoing TTM following cardiac arrest on the incidence of shivering. Methods A retrospective observational cohort study at a large academic medical center of adult patients who underwent TTM targeting 33 °C following out-of-hospital (OHCA) or in-hospital cardiac arrest (IHCA) was conducted between January 2013 and January 2019. Patients were included in the preprotocol group if they received TTM prior to the initiation of a pharmacologic antishivering protocol in 2015. The primary outcome was incidence of shivering between pre- and postprotocol patients. Secondary outcomes included time from arrest (IHCA) or admission to the hospital (OHCA) to goal body temperature, total time spent at goal body temperature, and percentage of patients alive at discharge. All pharmacologic agents listed as part of the antishivering protocol were recorded. Results Fifty-one patients were included in the preprotocol group, and 80 patients were included in the postprotocol group. There were no significant differences in baseline characteristics between the groups, including percentage of patients experiencing OHCA (75% vs. 63%, p = 0.15) and time from arrest to return of spontaneous circulation (17.5 vs. 17.9 min, p = 0.96). Incidence of patients with shivering was significantly reduced in the postprotocol group (57% vs. 39%, p = 0.03). Time from arrest (IHCA) or admission to the hospital (OHCA) to goal body temperature was similar in both groups (5.1 vs. 5.3 h, p = 0.57), in addition to total time spent at goal body temperature (17.7 vs. 18 h, p = 0.93). The percentage of patients alive at discharge was significantly improved in the postprotocol group (35% vs. 55%, p = 0.02). Patients in the postprotocol group received significantly more buspirone (4% vs. 73%, p < 0.01), meperidine (8% vs. 34%, p < 0.01), and acetaminophen (12% vs. 65%, p < 0.01) as part of the pharmacologic antishivering protocol. Use of neuromuscular blockade significantly decreased post protocol (19% vs. 6%, p = 0.02). Conclusions In patients undergoing TTM following cardiac arrest, the implementation of a pharmacologic antishivering protocol reduced the incidence of shivering and the use neuromuscular blocking agents. Prospective data are needed to validate the results and further evaluate the safety and efficacy of an antishivering protocol on clinical outcomes.

scholarly journals Extracorporeal Cardiopulmonary Resuscitation for Out‐of‐Hospital Cardiac Arrest in Adult Patients

2020 ◽  
Vol 9 (7) ◽  
Author(s):  
Akihiko Inoue ◽  
Toru Hifumi ◽  
Tetsuya Sakamoto ◽  
Yasuhiro Kuroda
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
The United States ◽  
Adult Patients ◽  
Temperature Management ◽  
Secondary Brain Injury ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Hospital Cardiac Arrest

Abstract Extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management has been demonstrated to significantly improve the outcomes of out‐of‐hospital cardiac arrest (OHCA) in adult patients. Although recent narrative and systematic reviews on extracorporeal life support in the emergency department are available in the literature, they are focused on the efficacy of ECPR, and no comprehensively summarized review on ECPR for OHCA in adult patients is available. In this review, we aimed to clarify the prevalence, pathophysiology, predictors, management, and details of the complications of ECPR for OHCA, all of which have not been reviewed in previous literature, with the aim of facilitating understanding among acute care physicians. The leading countries in the field of ECPR are those in East Asia followed by those in Europe and the United States. ECPR may reduce the risks of reperfusion injury and deterioration to secondary brain injury. Unlike conventional cardiopulmonary resuscitation, however, no clear prognostic markers have been identified for ECPR for OHCA. Bleeding was identified as the most common complication of ECPR in patients with OHCA. Future studies should combine ECPR with intra‐aortic balloon pump, extracorporeal membrane oxygenation flow, target blood pressure, and seizure management in ECPR.

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