scholarly journals Which Target Temperature for Post-Anoxic Brain Injury? A Systematic Review from “Real Life” Studies

2021 ◽  
Vol 11 (2) ◽  
pp. 186
Author(s):  
Andrea Minini ◽  
Filippo Annoni ◽  
Lorenzo Peluso ◽  
Elisa Gouvêa Bogossian ◽  
Jacques Creteur ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Real Life ◽  
Epidemiological Studies ◽  
Temperature Management ◽  
Target Temperature ◽  
Large Randomized Clinical Trial ◽  
Surveillance Programs ◽  
Initial Rhythm ◽  
Optimal Target

There is a persistent debate on the optimal target temperature to use during cooling procedures in cardiac arrest survivors. A large randomized clinical trial (RCT) including more than 900 patients showed that targeted temperature management (TTM) at 33 °C had similar mortality and unfavorable neurological outcome (UO) rates as TTM at 36 °C in out-of-hospital cardiac arrest patients with any initial rhythm. Since then, several observational studies have been published on the effects of changes in target temperature (i.e., from 33 to 36 °C) on patients’ outcome. We performed a systematic literature search from 1 January 2014 to 4 December 2020 and identified ten retrospective studies (very low levels of certainty; high risk of bias), including 5509 patients, that evaluated TTM at 33 °C vs. TTM at 36 °C on the occurrence of UO (n = eight studies) and mortality (n = ten studies). TTM at 33 °C was associated with a lower risk of UO when studies assessing neurological outcome with the Cerebral Performance Categories were analyzed (OR 0.80 [95% CIs 0.72–0.98]; p = 0.03). No differences in mortality were observed within the two TTM strategies. These results suggest that an inappropriate translation of TTM protocols from large well-conducted randomized trials into clinical management may result in unexpected effects on patients’ outcome. As for all newly commercialized drugs, epidemiological studies and surveillance programs with an adequate follow-up on large databases are necessary to understand how RCTs are implemented into medical practice.

Abstract 23: The Usefulness of Neuron-Specific Enolase in Cerebrospinal Fluid to Predict Neurological Prognosis in Cardiac Arrest Survivors Who Underwent Target Temperature Management: A Prospective Observational Study

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Jung Soo Park
Keyword(s):  
Cerebrospinal Fluid ◽  
Cardiac Arrest ◽  
Observational Study ◽  
Neurological Outcome ◽  
Prospective Observational Study ◽  
Neurologic Outcome ◽  
Temperature Management ◽  
Target Temperature Management ◽  
Target Temperature ◽  
Outcome Group

Aim: We aimed to investigate the prognostic performance between serum NSE and cerebrospinal fluid (CSF) NSE for 6-month neurologic outcome in OHCA survivors underwent target temperature management (TTM). Hypothesis: We hypothesized that the NSE levels measured in the CSF would affect the change, earlier and more sensitively than serum, according to severity of hypoxic brain damage. Methods: This single-centre prospective observational study included out-of-hospital cardiac arrest (OHCA) patients underwent TTM. NSE levels were assessed in blood and CSF samples obtained immediately (Day 0), and 24 h (Day 1), 48 h (Day 2), and 72 h (Day 3) after return of spontaneous circulation (ROSC). The primary outcome was the 6-month neurological outcome. Results: We enrolled 34 patients (males, 24; 70.6%), 16 (47.1%) had a poor neurologic outcome. CSF NSE and serum NSE values were significantly higher in the poor outcome group compared to the good outcome group at each time point, except for serum Day 0. CSF NSE and serum NSE had area under curve (AUC) of 0.819-0.972 and 0.648-0.920, respectively. CSF NSE prognostic performances were significant higher than serum NSE at Day 1 and showed excellent AUC values (0.969; 95% Confidential Interval [CI] 0.844-0.999) and high sensitivity (93.8%; 95% CI 69.8-99.8) at 100% specificity. Conclusion: We found CSF NSE values were highly predictive and sensitive markers of 6-month poor neurological outcome in OHCA survivors treated with TTM at Day 1 after ROSC. Thus, CSF NSE level at day 1 after ROSC can be a useful early prognosticator in OHCA survivors.

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 High Quality Targeted Temperature Management (TTM) After Cardiac Arrest

Critical Care ◽  
2020 ◽  
Vol 24 (1) ◽  
Author(s):  
Fabio Silvio Taccone ◽  
Edoardo Picetti ◽  
Jean-Louis Vincent
Keyword(s):  
Cardiac Arrest ◽  
Complex Intervention ◽  
Neurological Outcome ◽  
Targeted Temperature Management ◽  
Temperature Management ◽  
Target Temperature ◽  
High Quality ◽  
Large Variability ◽  
Anoxic Injury

AbstractTargeted temperature management (TTM) is a complex intervention used with the aim of minimizing post-anoxic injury and improving neurological outcome after cardiac arrest. There is large variability in the devices used to achieve cooling and in protocols (e.g., for induction, target temperature, maintenance, rewarming, sedation, management of post-TTM fever). This variability can explain the limited benefits of TTM that have sometimes been reported. We therefore propose the concept of “high-quality TTM” as a way to increase the effectiveness of TTM and standardize its use in future interventional studies.

scholarly journals Circulating Levels of miR-574-5p Are Associated with Neurological Outcome after Cardiac Arrest in Women: A Target Temperature Management (TTM) Trial Substudy

2019 ◽  
Vol 2019 ◽  
pp. 1-10 ◽  
Author(s):  
Adeline Boileau ◽  
Antonio Salgado Somoza ◽  
Josef Dankiewicz ◽  
Pascal Stammet ◽  
Patrik Gilje ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Neurological Outcome ◽  
Cerebral Performance Category ◽  
Temperature Management ◽  
Target Temperature Management ◽  
Target Temperature ◽  
Circulating Micrornas ◽  
Performance Category ◽  
Poor Neurological Outcome ◽  
Circulating Levels

Purpose. Postresuscitation neuroprognostication is guided by neurophysiological tests, biomarker measurement, and clinical examination. Recent investigations suggest that circulating microRNAs (miRNA) may help in outcome prediction after cardiac arrest. We assessed the ability of miR-574-5p to predict neurological outcome after cardiac arrest, in a sex-specific manner. Methods. In this substudy of the Target Temperature Management (TTM) Trial, we enrolled 590 cardiac arrest patients for which blood samples were available. Expression levels of miR-574-5p were measured by quantitative PCR in plasma samples collected 48 h after cardiac arrest. The endpoint of the study was poor neurological outcome at 6 months (cerebral performance category scores 3 to 5). Results. Eighty-one percent of patients were men, and 49% had a poor neurological outcome. Circulating levels of miR-574-5p at 48 h were higher in patients with a poor neurological outcome at 6 months (p<0.001), both in women and in men. Circulating levels of miR-574-5p were univariate predictors of neurological outcome (odds ratio (OR) [95% confidence interval (CI)]: 1.5 [1.26-1.78]). After adjustment with clinical variables and NSE, circulating levels of miR-574-5p predicted neurological outcome in women (OR [95% CI]: 1.9 [1.09-3.45]), but not in men (OR [95% CI]: 1.0 [0.74-1.28]). Conclusion. miR-574-5p is associated with neurological outcome after cardiac arrest in women.

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 ◽  
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

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.

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