scholarly journals Therapeutic hypothermia in Post - cardiac arrest : It is time to revisit the guidelines.

2018 ◽  
Vol 6 (2) ◽  
pp. 84-87
Author(s):  
Afroz Shirin ◽  
Tasbirul Islam
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Neurological Outcome ◽  
Neurological Injury ◽  
Temperature Management ◽  
Potential Harm ◽  
Neurological Outcomes ◽  
Different Temperatures ◽  
Favorable Neurological Outcome

Background: Targeted Temperature Management (TTM), previously known as therapeutic hypothermia is an important tool for prevention and reversal of neurological injury and mortality reduction. Over the recent period, the use of induced hypothermia has raised many questions and recent large, randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. The objective of this article was to compare different studies on neurological outcomes after use of TTM in different clinical situations, different temperatures and rates of cooling.Methods: We incorporated studies from 1950s to recent years using search engines like PubMed, Science Direct, Google Scholar.Results: Initial two small, unblinded trials have demonstrated improved neurological outcome in out of hospital shockable cardiac arrest. Recent studies showed that TTM was not associated with higher rates of survival or favorable neurological outcome in patients with IHCA and was rather associated with potential harm, lower likelihood of survival after discharge and long term neurological survival. TTM also didn’t show any favorable results in non-shockable cardiac arrests. Hypothermia of 36°C did not confer much benefit over 32°C -34°C.Conclusion: Recent large studies didn’t show no strong evidence that TTM is highly effective. Further methodologically robust studies are required in both shockable and non-shockable cardiac arrest for TTM to have any effect on neurological outcome.Bangladesh Crit Care J September 2018; 6(2): 84-87

Abstract 340: Early Invasive Hemodynamics and Outcomes in Cardiac Arrest Survivors Undergoing Targeted Temperature Management

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Aldo L Schenone ◽  
Kevin Chen ◽  
Bashaer Gheyath ◽  
Nyal Borges ◽  
Manshi Li ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Discharge ◽  
Neurological Outcome ◽  
Wide Spectrum ◽  
Temperature Management ◽  
Neurological Outcomes ◽  
Pulmonary Capillary ◽  
Wide Variability ◽  
Favorable Neurological Outcome ◽  
Invasive Hemodynamics

Introduction: Clinical and electrical determinants of survival following cardiac arrest (CA) have been well defined. The prognostic role of early invasive hemodynamics (iHDs) remains unknown. Hypothesis: Early iHDs following CA in survivors undergoing TTM predicts survival and neurological outcomes at hospital discharge. Methods: We reviewed prospectively collected data on CA survivors undergoing TTM in a quaternary CICU between Jan 15 and Jun 17. Patients included were required to have RHC derived iHDs at initiation of TTM. Subjects with cooling initiated before admission and temperature of <36°C prior to obtaining iHDs were excluded. Univariate and multivariate regression were conducted to test whether cardiac index (Fick-CI≥2.2 vs <2.2 liters/min per m 2 ), pulmonary capillary wedge pressure (PCWP≥18 vs <18mmHg), systemic vascular resistance (SVR>1200 vs 800-1200 vs <800 dynes·sec·cm -5 ) or Forrester hemodynamic profiles were predictive of survival and favorable neurological outcomes at hospital discharge. Results: We identified 52 subjects and 26 (50%) survived to hospital discharge, with 21 (40%) achieving a favorable neurological outcome. Wide variability in invasive hemodynamic parameters was noted in this cohort. There was no association between Fick-CI (p=0.45 & p=0.10), PCWP (p=0.90 & p=0.60), SVR (0.95 & p=0.17) or Forrester hemodynamic profiles (p=0.40 & p=0.42) and survival or favorable neurological outcome at discharge. Conclusion: CA survivors undergoing TTM present with a wide spectrum of iHDs highlighting the heterogeneity of the post cardiac arrest syndrome. Early iHDs did not predict survival or neurological outcomes at hospital discharge.

Abstract 347: The Effect of Targeted Temperature Management at 34 °C and 36 °C on Day-30 Neurological Outcomes in Out-of-hospital Cardiac Arrest Patients

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Takeshi Iyonaga ◽  
Ken-ichi Hiasa ◽  
Nobuyuki Enzan ◽  
Masaaki A Nishihara ◽  
Kenzo Ichimura ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Multivariable Analysis ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Target Temperature ◽  
Neurological Outcomes ◽  
Favorable Neurological Outcome ◽  
The Relationship ◽  
Hospital Cardiac Arrest

Introduction: Targeted temperature management (TTM) has established evidence for improving neurological outcomes in cardiac arrest patients who sustained coma after return of spontaneous circulation (ROSC). The target temperature has been recommended to be between 32 and 36 °C. However optimal temperature remains unestablished. This study aimed to assess the relationship between target temperature and neurological outcome by using the Japanese nationwide registry. Methods: This retrospective observational cohort study was based on the Japanese association for acute medicine - out-of-hospital cardiac arrest (JAAM-OHCA) registry during 2014 to 2017. Our study included all initial rhythms and any cause of OHCA patients and excluded age < 18 and Glasgow Coma Scale score > 8. The primary outcome was 30 day favorable neurological outcome, defined as cerebral performance category (CPC) scale 1 and 2. First, to clarify the efficacy of TTM, the neurological outcome was compared whether patients received TTM or not. Next, to evaluate the relationship between neurological outcome and target temperature on TTM, the neurological outcome was compared hypothermia (34 °C) group with normothermia (36 °C) group . Single and multivariable logistic regression analysis was performed. Results: The study included 9930 patients. Of these, 1184 (11.9%) patients received TTM. Favorable neurological outcome was more present in TTM group than in no TTM group (39.7% vs. 4.3%, odds ratio [OR] 14.6, 95% confidence interval [CI] 12.5-17.1, p<0.001). Multivariable analysis showed TTM was associated with favorable neurological outcome (OR 1.6, 95%CI 1.1-2.3, p<0.001). Of TTM group, 801 (68.5%) patients received hypothermia management and 242 (20.7%) patients received normothermia management. Favorable neurological outcome was more present in the hypothermia group than in the normothermia group (42.6% vs. 34.3%, OR 1.42, 95% CI 1.1-1.9, p=0.022). However, the neurological outcome did not differ between these two groups (OR 0.84, 95%CI 0.46-1.5, p<0.57). Conclusions: TTM was significantly associated with favorable neurological outcome. However, neurological outcome was not associated with target temperature on TTM.

Abstract 161: Effectiveness of Lower Target Temperature Therapeutic Hypothermia for Post--Cardiac Arrest Victims Within 30 Minutes Resuscitation Interval

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Tadashi Kaneko ◽  
Shunji Kasaoka ◽  
Ken Nagao ◽  
Naohiro Yonemoto ◽  
Hiroyuki Yokoyama ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Therapeutic Hypothermia ◽  
Neurological Outcome ◽  
Propensity Score Analysis ◽  
Spontaneous Circulation ◽  
Temperature Management ◽  
Target Temperature Management ◽  
Target Temperature ◽  
Weighting Method ◽  
Favorable Neurological Outcome

Introduction: Therapeutic hypothermia (TH) for post cardiac arrest syndrome (PCAS) patients is standard strategy to reduce brain damage. However, current randomized control study (TTM: Target temperature management study, N Engl J Med 2013) suggested that simple target temperature did not improve outcome. Furthermore, there is no evidence, whether target temperature would be changed for each status of PCAS patients. Hypothesis: Lower target temperature could improve neurological outcome in PCAS patients. Methods: Participants with J-PULSE-Hypo study database were divided into the L group (32.0-33.9°C) and the M group (34-35°C). The favorable neurological outcomes (%, CPC 1-2 on 30th day) were compared between L and M groups in all and each subgroups with propensity score analysis with IPTW (inverse probability of treatment weighting) method as multivariate analysis. The subgroups were ages and interval from collapse to ROSC (return of spontaneous circulation). Results: 477 participants were analyzed. The comparison of each groups for favorable neurological outcome were that all groups (L: 64%, n = 42, vs M: 55%, n= 424, P = 0.234, multivariate: P = 0.452), age (≤60 y.o.) (L: 70% vs M: 67%, P = 0.717, multivariate: P = 0.657), age (>60 y.o.) (L: 50% vs M: 44%, P = 0.665, multivariate: P = 0.061), interval from collapse to ROSC (≤30 min.) (L: 88% vs M: 64%, P = 0.022, multivariate: P = 0.007), and interval from collapse to ROSC (>30 min.) (L: 21% vs M: 29%, P = 0.567, multivariate: P = 0.449). Conclusions: The PCAS victims within 30 min. from collapse to ROSC, would be treated by TH with less than 34°C target temperature.

Abstract 199: Pulmonary Embolism and Accidental Hypothermia Have a Favorable Outcome in Cardiac Arrest With PEA Treated by ECPR

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_2) ◽  
Author(s):  
Shinichi Ijuin ◽  
Akihiko Inoue ◽  
Nobuaki Igarashi ◽  
Shigenari Matsuyama ◽  
Tetsunori Kawase ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Cerebral Performance Category ◽  
Accidental Hypothermia ◽  
Neurological Outcomes ◽  
Good Outcome ◽  
Group B ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Introduction: We have reported previously a favorable neurological outcome by extracorporeal cardiopulmonary resuscitation (ECPR) for out of hospital cardiac arrest. However, effects of ECPR on patients with prolonged pulseless electrical activity (PEA) are unclear. We analyzed etiology of patients with favorable neurological outcomes after ECPR for PEA with witness. Methods: In this single center retrospective study, from January 2007 to May 2018, we identified 68 patients who underwent ECPR for PEA with witness. Of these, 13 patients (19%) had good neurological outcome at 1 month (Glasgow-Pittsburgh Cerebral Performance Category (CPC):1-2, Group G), and 55 patients (81%) had unfavorable neurological outcome (CPC:3-5, Group B). We compared courses of treatment and causes/places of arrests between two groups. Results are expressed as mean ± SD. Results: Patient characteristics were not different between the two groups. Time intervals from collapse to induction of V-A ECMO were also not significantly different (Group G; 46.1 ± 20.2 min vs Group B; 46.8 ± 21.7 min, p=0.92). Ten patients achieved favorable neurological outcome among 39 (26%) with non-cardiac etiology. In cardiac etiology, only 3 of 29 patients (9%) had a good outcome at 1 month (p=0.08). In particular, 5 patients of 10 pulmonary embolism, and 4 of 4 accidental hypothermia responded well to ECPR with a favorable neurological outcome. Additionally, 6 of 13 (46%), who had in hospital cardiac arrest, had good outcome, whereas 7 of 55 (15%) who had out of hospital cardiac arrest, had good outcome (p=0.02). Conclusions: In our small cohort of cardiac arrest patients with pulmonary embolism or accidental hypothermia and PEA with witness, EPCR contributed to favorable neurological outcomes at 1 month.

Usefulness of the Degree of Blood–brain Barrier Disruption to Predict Neurological Prognosis in Cardiac Arrest Survivors who Wnderwent Target Temperature Management: A Retrospective Study

2020 ◽  
Author(s):  
Ga Ram Jeon ◽  
Hong Joon Ahn ◽  
Jung Soo Park ◽  
Insool Yoo ◽  
Yeonho You ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Blood Brain Barrier ◽  
Neurological Outcome ◽  
Scoring System ◽  
Brain Barrier ◽  
Temperature Management ◽  
Target Temperature Management ◽  
Target Temperature ◽  
Neurological Outcomes ◽  
Poor Neurological Outcome

Abstract Background: This study aimed to compare the day-specific association of blood–brain barrier (BBB) disruption with neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors treated with target temperature management (TTM).Methods: This retrospective single-center study included 68 OHCA survivors, who underwent TTM between April 2018 and December 2019. The albumin quotient (QA) was calculated as [albuminCSF] / [albuminserum] immediately (day 1), and at 24 h (day 2), 48 h (day 3), and 72 h (day 4) after return of spontaneous circulation (ROSC). The degree of BBB disruption was weighted using the following scoring system: 0.07 ≥ QA (normal), 0.01 ≥ QA > 0.007 (mild), 0.02 ≥ QA > 0.01 (moderate), and QA > 0.02 (severe). This system gave it 0 (normal), 1 (mild), 4 (moderate), and 9 (severe) points. Poor neurological outcome was determined at six months after ROSC and was defined as cerebral performance categories 3–5.Results: We enrolled 68 patients (males, 48; 71%); 37 (54%) of them had a poor neurological outcome. The distributions of this outcome at six months in patients with moderate and severe BBB disruption versus the other groups were 19/22 (80%) vs. 18/46 (50%) on day 1, 31/37 (79%) vs. 6/31 (32%) on day 2, 32/37 (81%) vs. 5/31 (30%) on day 3, and 32/39 (85%) vs. 5/29 (30%) on day 4 (P < 0.001). Using ROC analyses, the optimal cutoff values of QA levels for prediction of neurological outcomes were determined as: day 1, > 0.009 (sensitivity 56.8%, specificity 87.1%); day 2, > 0.012 (sensitivity 81.1%, specificity 87.1%); day 3, > 0.013 (sensitivity 83.8%, specificity 87.1%); day 4, > 0.013 (sensitivity 86.5%, specificity 87.1%); sum of all time points, > 0.039 (sensitivity 89.5%, specificity 79.4%); and scoring system, > 9 (sensitivity 91.9%, specificity 87.1%). Conclusions: Our results suggested that QA is a useful tool for predicting neurological outcomes in OHCA survivors treated with TTM. However, the prediction of poor neurological outcome using QA showed low sensitivity at 100% specificity. Thus, it could be used as part of a multimodal approach than as a single prognostic prediction tool.

scholarly journals Impact of Total Epinephrine Dose on Long Term Neurological Outcome for Cardiac Arrest Patients: A Cohort Study

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiaowei Shi ◽  
Jiong Yu ◽  
Qiaoling Pan ◽  
Yuanqiang Lu ◽  
Lanjuan Li ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Confidence Interval ◽  
Neurological Outcome ◽  
Univariate Analysis ◽  
Term Effect ◽  
Term Survival ◽  
Long Term Effect ◽  
Epinephrine Dose ◽  
Favorable Neurological Outcome

Introduction: Although epinephrine is universally acknowledged to increase return of spontaneous circulation (ROSC) after cardiac arrest, its balanced effects on later outcomes remain uncertain, causing potential harm during post-resuscitation phase. Recent studies have questioned the efficacy and potential deleterious effects of epinephrine on long-term survival and neurological outcomes, despite that the adverse relationship between epinephrine dose and outcome can be partially biased by longer CPR duration and underlying comorbidities. This study explored the long-term effect of epinephrine when used in a cohort of patients that underwent cardiac arrest during cardiopulmonary resuscitation.Methods: The data were originally collected from a retrospective institutional database from January 2007 to December 2015 and are now available on Dryad (via: https://doi.org/10.5061/dryad.qv6fp83). Use of epinephrine was coded by dose (&lt;2 mg, 2 mg, 3–4 mg, ≥5 mg). A favorable neurological outcome was defined using a Cerebral Performance Category (CPC) 1 or 2. The association between epinephrine dosing and 3-months neurological outcome was analyzed by univariate analysis and multivariate logistic regression.Results: Univariate and multivariate analysis demonstrated a negative association between total epinephrine dose and neurological outcome. Of the 373 eligible patients, 92 received less than 2 mg of epinephrine, 60 received 2 mg, 97 received 3–4 mg and 124 received more than 5 mg. Compared to patients who received less than 2 mg of epinephrine, the adjusted odds ratio (OR) of a favorable neurological outcome was 0.8 (95% confidence interval [CI]: 0.38–1.68) for 2 mg of epinephrine, 0.43 (95% confidence interval [CI]: 0.21–0.89) for 3–4 mg of epinephrine and 0.40 (95% confidence interval [CI]: 0.17–0.96) for more than 5 mg of epinephrine.Conclusion: In this cohort of patients who achieved ROSC, total epinephrine dosing during resuscitation was associated with a worse neurological outcome three months after cardiac arrest, after adjusting other confounding factors. Further researches are needed to investigate the long-term effect of epinephrine on cardiac arrest patients.

scholarly journals Optimal cardiopulmonary resuscitation duration for favorable neurological outcomes after out-of-hospital cardiac arrest

2022 ◽  
Vol 30 (1) ◽  
Author(s):  
SungJoon Park ◽  
Sung Woo Lee ◽  
Kap Su Han ◽  
Eui Jung Lee ◽  
Dong-Hyun Jang ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Neurological Outcome ◽  
Patient Characteristics ◽  
Related Factors ◽  
Neurological Outcomes ◽  
Upper Limit ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest ◽  
Off Time

Abstract Background A favorable neurological outcome is closely related to patient characteristics and total cardiopulmonary resuscitation (CPR) duration. The total CPR duration consists of pre-hospital and in-hospital durations. To date, consensus is lacking on the optimal total CPR duration. Therefore, this study aimed to determine the upper limit of total CPR duration, the optimal cut-off time at the pre-hospital level, and the time to switch from conventional CPR to alternative CPR such as extracorporeal CPR. Methods We conducted a retrospective observational study using prospective, multi-center registry of out-of-hospital cardiac arrest (OHCA) patients between October 2015 and June 2019. Emergency medical service–assessed adult patients (aged ≥ 18 years) with non-traumatic OHCA were included. The primary endpoint was a favorable neurological outcome at hospital discharge. Results Among 7914 patients with OHCA, 577 had favorable neurological outcomes. The optimal cut-off for pre-hospital CPR duration in patients with OHCA was 12 min regardless of the initial rhythm. The optimal cut-offs for total CPR duration that transitioned from conventional CPR to an alternative CPR method were 25 and 21 min in patients with initial shockable and non-shockable rhythms, respectively. In the two groups, the upper limits of total CPR duration for achieving a probability of favorable neurological outcomes < 1% were 55–62 and 24–34 min, respectively, while those for a cumulative proportion of favorable neurological outcome > 99% were 43–53 and 45–71 min, respectively. Conclusions Herein, we identified the optimal cut-off time for transitioning from pre-hospital to in-hospital settings and from conventional CPR to alternative resuscitation. Although there is an upper limit of CPR duration, favorable neurological outcomes can be expected according to each patient’s resuscitation-related factors, despite prolonged CPR duration.

Abstract 186: Sex Differences in Outcomes for Out-Of-Hospital Cardiac Arrest

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Pavitra Kotini-Shah ◽  
Oksana Pugach ◽  
Ruizhe Chen ◽  
Marina Del Rios ◽  
Kimberly Vellano ◽  
...  
Keyword(s):  
United States ◽  
Cardiac Arrest ◽  
Sex Differences ◽  
Coronary Angiography ◽  
Neurological Outcome ◽  
The United States ◽  
Neurological Outcomes ◽  
Bystander Cpr ◽  
Favorable Neurological Outcome ◽  
Hospital Cardiac Arrest

Introduction: Approximately 1,000 out-of-hospital cardiac arrest (OHCA) occur per day in the United States. Although survival rates remains low, the extent to which OHCA neurological outcomes differ between men and women remains poorly characterized. Methods: Within the national Cardiac Arrest Registry to Enhance Survival (CARES) registry, we identified 195,722 adult individuals with an OHCA between 2013-2017. Using multi-variable logistic regression models, we evaluated for sex differences in rates of survival to hospital discharge and favorable neurological outcome (survival with discharge CPC score of 1 or 2), adjusted for cardiac arrest characteristics, race, location, year of arrest, age, and use of targeted temperature management (TTM) and coronary angiography. Results: Overall, 70,767 (31%) patients were women. Median age was 64 and 62 years for women and men, respectively. An initial shockable rhythm (14.9% vs. 25.7%) and a witnessed arrest (40.9% vs. 45.6%) was more common in men. Bystander CPR was provided to 37% of women and 39% of men. Men were less likely to survive to hospital discharge than women (8.7% vs. 10.9%; adjusted OR 0.75, 95% CI 0.73, 0.78). Similarly, men were less likely to have favorable neurological outcome (6.6% vs. 9.2% for women; adjusted OR 0.78, 95% CI 0.74, 0.82). Further interaction analysis for the pre-hospital elements found small, but statistically significant sex differences in favorable neurological survival for witnessed status (among female OR 2.29, 95% CI 2.10, 2.49; among males OR 2.07, 95% CI 1.92, 2.23, p= 0.04) and for bystander CPR (among females OR 1.20, 95% CI 1.11, 1.29; among males OR 1.34, 95% CI 1.27, 1.42, p= 0.01). Interaction of sex with the hospital level variables of TTM and coronary angiography, for the subset of patients that survived to hospital admission, had no sex differences in favorable neurological outcome. Conclusion: Our analysis shows that for OHCA in the United States, women have better survival outcomes than men. There was a sex differences in the pre-hospital variable of BCPR, but not in the other modifiable variables of TTM and coronary angiography. Further study is needed to better understand sex differences in overall survival and neurological outcomes.

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