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Intra-arrest hypothermia during cardiac arrest: a systematic review
Sabino Scolletta, Fabio Taccone, Per Nordberg, Katia Donadello, Jean-Louis Vincent, Maaret Castren
Critical Care , 2012, DOI: 10.1186/cc11235
Abstract: We performed a systematic search of PubMed, EMBASE, CINAHL, the Cochrane Library and Ovid/Medline databases using "arrest" OR "cardiac arrest" OR "heart arrest" AND "hypothermia" OR "therapeutic hypothermia" OR "cooling" as keywords. Only studies using intra-arrest therapeutic hypothermia (IATH) were selected for this review. Three authors independently assessed the validity of included studies and extracted data regarding characteristics of the studied cohort (animal or human) and the main outcomes related to the use of IATH: Mortality, neurological status and cardiac function (particularly, rate of ROSC).A total of 23 animal studies (level of evidence (LOE) 5) and five human studies, including one randomized controlled trial (LOE 1), one retrospective and one prospective controlled study (LOE 3), and two prospective studies without a control group (LOE 4), were identified. IATH improved survival and neurological outcomes when compared to normothermia and/or hypothermia after ROSC. IATH was also associated with improved ROSC rates and with improved cardiac function, including better left ventricular function, and reduced myocardial infarct size, when compared to normothermia.IATH improves survival and neurological outcome when compared to normothermia and/or conventional hypothermia in experimental models of CA. Clinical data on the efficacy of IATH remain limited.Use of mild therapeutic hypothermia, or "targeted temperature management" as recently suggested [1], has been recommended in cardiac arrest (CA) patients since the publication of two randomized clinical trials in 2002, the results of which demonstrated a significant improvement in neurologically intact survival for comatose CA patients presenting with ventricular fibrillation (VF) or ventricular tachycardia (VT) [2,3]. Current guidelines suggest that mild therapeutic hypothermia should also be considered in patients presenting with other rhythms although this has been less well studied [4].Although therap
A Comparison of Cooling Techniques to Treat Cardiac Arrest Patients with Hypothermia  [PDF]
Anna Finley Caulfield,Shylaja Rachabattula,Irina Eyngorn,Scott A. Hamilton,Rajalakshmi Kalimuthu,Amie W. Hsia,Maarten G. Lansberg,Chitra Venkatasubramanian,J. J. Baumann,Marion S. Buckwalter,Monisha A. Kumar,James S. Castle,Christine A. C. Wijman
Stroke Research and Treatment , 2011, DOI: 10.4061/2011/690506
Abstract: Introduction. We sought to compare the performance of endovascular cooling to conventional surface cooling after cardiac arrest. Methods. Patients in coma following cardiopulmonary resuscitation were cooled with an endovascular cooling catheter or with ice bags and cold-water-circulating cooling blankets to a target temperature of 32.0–34.0°C for 24 hours. Performance of cooling techniques was compared by (1) number of hourly recordings in target temperature range, (2) time elapsed from the written order to initiate cooling and target temperature, and (3) adverse events during the first week. Results. Median time in target temperature range was 19 hours (interquartile range (IQR), 16–20) in the endovascular group versus. 10 hours (IQR, 7–15) in the surface group ( ). Median time to target temperature was 4 (IQR, 2.8–6.2) and 4.5 (IQR, 3–6.5) hours, respectively ( ). Adverse events were similar. Conclusion. Endovascular cooling maintains target temperatures better than conventional surface cooling. 1. Introduction Each year an estimated 165,000 people in the United States have an out-of-hospital cardiac arrest, and many more undergo in-hospital resuscitation [1–4]. Those that survive may have devastating neurological impairments from global ischemic brain injury. Mild-to-moderate therapeutic hypothermia for 12 to 24 hours has been shown to improve neurological outcome in two randomized clinical trials of comatose survivors following out-of-hospital ventricular fibrillation arrest [5, 6]. Based on the results of these trials, the 2005 American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended to consider the use of therapeutic hypothermia for unconscious adult patients with return of spontaneous circulation after witnessed out-of-hospital ventricular fibrillation arrest (Class IIA) and nonventricular fibrillation and in-hospital cardiac arrest (Class IIB) [7]. The 2010 guidelines continue to recommend therapeutic hypothermia in these patients, now as Class I and Class IIB recommendations, respectively [8]. In spite of the data and guidelines hospitals in the United States have been slow to adopt therapeutic hypothermia in the routine management of comatose postcardiac arrest patients [9]. This may be in part explained by physician unfamiliarity with therapeutic hypothermia and in part by the labor intensiveness and inaccuracy of surface cooling using ice bags and cooling blankets [10]. Most studies to date have used conventional surface-based cooling techniques (ice bags and cool air or water
Improved Survival with Therapeutic Hypothermia after Cardiac Arrest with Cold Saline and Surfacing Cooling: Keep It Simple  [PDF]
Cristina Granja,Pedro Ferreira,Orquídea Ribeiro,Jo？o Pina
Emergency Medicine International , 2011, DOI: 10.1155/2011/395813
Abstract: Aim. To evaluate whether the introduction of a therapeutic hypothermia (TH) protocol consisting of cold saline infusion and surface cooling would be effective in targeting mild therapeutic hypothermia (32–34°C). Additionally, to evaluate if TH would improve survival after cardiac arrest. Design. Before-after design. Setting. General Intensive Care Unit (ICU) at an urban general hospital with 470 beds. Patients and Methods. Patients admitted in the ICU after cardiac arrest between 2004 and 2009 were included. Effectiveness of the TH protocol to achieve the targeted temperature was evaluated. Hospital mortality was compared before (October 2004–March 2006) and after (April 2006–September 2009) the protocol implementation. Results. Hundred and thirty patients were included, 75 patients were not submitted to TH (before TH group), and 55 were submitted to TH (TH group). There were no significant differences concerning baseline, ICU, and cardiac arrest characteristics between both groups. There was a significant reduction in hospital mortality from 61% ( ) in the before TH group to 40% ( ) in the TH group. Conclusion. Our protocol consisting of cold saline infusion and surface cooling might be effective in inducing and maintaining mild therapeutic hypothermia. TH achieved with this protocol was associated with a significant reduction in hospital mortality. 1. Introduction The outcome after cardiac arrest is still poor [1], with only 7% to 30% of the patients being discharged from hospital with good neurologic outcome [1]. Therapeutic hypothermia (TH) can improve survival and the neurological outcome [2, 3] after cardiac arrest. Previous and current guidelines recommend TH in comatose survivors of cardiac arrest associated with nonshockable rhythms as well as shockable rhythms, acknowledging, however, the lower level of evidence for use after cardiac arrest from non-shockable rhythms [4, 5]. The effect of hypothermia on the neurological outcome would seem to be most beneficial when the treatment is initiated as early as possible after restoration of spontaneous circulation (ROSC) and maintained for 12–24？h [6]. A recent metanalysis [1, 7] and a revision of the literature [8] have confirmed the benefit of the TH even outside the scope of randomized controlled trials. While several methods of cooling are currently applied [6–14], there is no proof of superiority of any cooling method above others, and there are currently no formal cost-benefit analyses [1]. Surface cooling is generally considered the least expensive and is probably the most widely used [15–17].
Efficacy of and tolerance to mild induced hypothermia after out-of-hospital cardiac arrest using an endovascular cooling system
Nicolas Pichon, Jean Amiel, Bruno Fran？ois, Anthony Dugard, Caroline Etchecopar, Philippe Vignon
Critical Care , 2007, DOI: 10.1186/cc5956
Abstract: This study was conducted in the medical-surgical intensive care unit of an urban university hospital. Forty patients admitted to the intensive care unit following out-of-hospital cardiac arrest underwent mild induced hypothermia (MIH). Core temperature was monitored continuously for five days using a Foley catheter equipped with a temperature sensor. Any equipment malfunction was noted and all adverse events attributable to MIH were recorded. Neurological status was evaluated daily using the Pittsburgh Cerebral Performance Category (CPC). We also recorded the mechanism of cardiac arrest, the Simplified Acute Physiologic Score II on admission, standard biological variables, and the estimated time of anoxia. Nosocomial infections during and after MIH until day 28 were recorded.Six patients (15%) died during hypothermia. Among the 34 patients who completed the period of MIH, hypothermia was steadily maintained in 31 patients (91%). Post-rewarming 'rebound hyperthermia', defined as a temperature of 38.5°C or greater, was observed in 25 patients (74%) during the first 24 hours after cessation of MIH. Infectious complications were observed in 18 patients (45%), but no patient developed severe sepsis or septic shock. The biological changes that occurred during MIH manifested principally as hypokalaemia (< 3.5 mmol/l; in 75% of patients).The intravascular cooling system is effective, safe and allows a target temperature to be reached fairly rapidly and steadily over a period of 36 hours.Mild induced hypothermia (MIH) was recently shown to improve neurological outcomes in patients who had sustained post-resuscitation encephalopathy secondary to cardiac arrest [1-3]. Accordingly, this procedure has been recommended as part of the standard of care for out-of-hospital cardiac arrest [4]. Nevertheless, the optimal technique for achieving MIH and its benefit/risk ratio in the target population remain controversial [5]. Conventional techniques for effecting therapeutic hypothermia
Prehospital cooling in cardiac arrest - the next frontier?
Eldar S？reide
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-54
Abstract: Therapeutic hypothermia (TH) in unconscious survivors of out-of-hospital cardiac arrest (OHCA) is now a well-documented part of post-resuscitation care [1,2]. Implementation of TH into daily clinical practice has been far more successful in the Scandinavian countries than in the rest of the world [3,4]. Still, many questions remain unanswered:？ Is there a better, safer and more rapid way of cooling these patients?？ Does rapid cooling necessarily mean prehospital cooling?？ And, will rapid prehospital cooling translate into higher survival rates and better neurological outcomes?In this issue of the Journal, two international research groups within this exciting and rapidly progressing field of critical care medicine have reviewed the present knowledge on prehospital cooling in OHCA [5,6]. Behringer et al [5] give an excellent overview on what is known about prehospital preservative and resuscitative hypothermia. Their main focus is on resuscitative hypothermia - meaning cooling initiated after return of spontaneous circulation (ROSC). Both non-invasive cooling pads and IV. infusion of ice-cold fluids have been shown to be feasible alternatives in the prehospital environment, securing earlier induction of the cooling process. What is lacking is convincing human data on improved clinical outcomes. K？m？r？inen et al [6] come to the same conclusion. In their review they also mentioned a specially designed cooling cap as a possible method of (selective) brain cooling. They also review the present human data on prehospital intra-arrest cooling. After much promising animal data, little more than feasibility and safety data has been published in humans. However, this may all change in the next months to come.The Australian trial on prehospital cooling versus in-hospital cooling in OHCA survivors (RICH-trial) has been presented at an international medical meeting. The trial now has been broadened to include intra-arrest cooling as well (Stephen Bernard, personal communication).
Recent treatment of postischaemic anoxic brain damage after cardiac arrest by using therapeutic hypothermia
An？eli？ Sla？ana
Srpski Arhiv za Celokupno Lekarstvo , 2008, DOI: 10.2298/sarh0810549a
Abstract: Organ injury caused by ischemia and anoxia during prolonged cardiac arrest is compounded by reperfusion injury that occurs when spontaneous circulation is restored. Mild hypothermia (32-35oC) is neuroprotective through several mechanisms, including suppression of apoptosis, reduced production of excitotoxins and free radicals, and anti-inflammatory actions. Experimental studies show that hypothermia is more effective the earlier it is started after return of spontaneous circulation (ROSC). Two randomized clinical trials show improved survival and neurological outcome in adults who remained comatose after initial resuscitation from prehospital VF cardiac arrest, and who were cooled after ROSC. Different strategies can be used to induce hypothermia. Optimal timing of therapeutic hypothermia for cardiac ischemia is unknown. In patients who failed to respond to standard cardiopulmonary resuscitation, intra-arrest cooling using ice-cold intravenous (i.v.) fluid improved the chance of survival. Recently, fasudil, a Rho kinase inhibitor, was reported to prevent cerebral ischaemia in vivo by increasing cerebral blood flow and inhibiting inflammatory responses. In future, two different kinds of protective therapies, BCL-2 overexpression and hypothermia, will both inhibit aspects of apoptotic cell death cascades, and that combination treatment can prolong the temporal 'therapeutic window' for gene therapy.
Therapeutic hypothermia post out-of-hospital cardiac arrest - more questions than answers?
Richard Lyon
Critical Care , 2011, DOI: 10.1186/cc10123
Abstract: Patients post out-of-hospital cardiac arrest (OHCA) are common admissions to the ICU. Therapeutic hypothermia has been shown to improve both survival and neurological outcome for OHCA patients surviving to reach the ICU and now forms part of routine post-resuscitation care. The Time to Target Temperature (TTTT) study group presents key observations on the relationship between body temperature and outcome following OHCA [1], yet ultimately are we left with more questions than answers on therapeutic hypothermia?Nearly a decade ago two landmark papers fundamentally changed the practice of post-resuscitation care. The Hypothermia after Cardiac Arrest study group [2] and Bernard and colleagues [3] not only demonstrated the benefit of cooling OHCA patients but also highlighted how hugely effective the therapy was, with a number needed to treat of seven patients and six patients, respectively, for survival. Such impressive therapeutic benefit is rarely seen in medical practice, let alone in critical care medicine. A key difference between these two studies was the time from return of spontaneous circulation (ROSC) to the onset of cooling. The time to reach the target temperature (<34°C) varied greatly from immediately post ROSC to over 16 hours post ROSC and yet the therapeutic benefit of cooling was still evident. The TTTT group demonstrated that the change in body temperature during the period from ROSC to cooling initiation has a direct relationship on survival [1].Since 2002 few studies have examined the optimum method, rate of cooling and timing of initiation. Little is known about the mechanism of action of therapeutic hypothermia. Whilst animal evidence strongly suggests that early cooling, especially intra-arrest, is beneficial, few human studies have demonstrated a benefit from early cooling. Early cooling, in the prehospital or emergency department setting, has significant technical challenges and may distract from the basic principles of resuscitation. Yet emerg
Hypothermia and pediatric cardiac arrest  [cached]
Schlunt Michelle,Wang Lynn
Journal of Emergencies, Trauma and Shock , 2010,
Abstract: The survival outcome following pediatric cardiac arrest still remains poor. Survival to hospital discharge ranges anywhere from 0 to 38% when considering both out-of-hospital and in-hospital arrests, with up to 50% of the survivors having neurologic injury. The use of mild induced hypothermia has not been definitively proven to improve outcomes following pediatric cardiac arrest. This may be due to the lack of consensus regarding target temperature, best method of cooling, optimal duration of cooling and identifying the patient population who will receive the greatest benefit. We review the current applications of induced hypothermia in pediatric patients following cardiac arrest after searching the current literature through Pubmed and Ovid journal databases. We put forth compiled recommendations/guidelines for initiating hypothermia therapy, its maintenance, associated monitoring and suggested adjunctive therapies to produce favorable neurologic and survival outcomes.
Out-of-hospital therapeutic hypothermia in cardiac arrest victims
Wilhelm Behringer, Jasmin Arrich, Michael Holzer, Fritz Sterz
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-52
Abstract: Sudden cardiac arrest remains a major unresolved public health problem. In Europe and the USA, approximately 425.000 people suffer of sudden cardiac death with very poor survival, usually less than 10% [1,2]. After cardiac arrest and brain ischemia, reperfusion initiates multiple independent chemical cascades and fatal pathways, resulting in neuronal death due to necrosis and apoptosis [3]. Because of the multi-factorial pathogenesis of post-arrest neuronal death, a multifaceted treatment strategy is required to achieve survival without brain damage. Hypothermia, a re-discovered promising treatment strategy, exerts its beneficial effects on brain ischemia by various mechanisms, and perfectly fulfils the requirements of a multifaceted treatment strategy [4].In therapeutic hypothermia, different degrees of cooling can be differentiated, though definition of these temperature levels may differ slightly between authors: mild (34 to 32°C), moderate (31 to 28°C), deep (27 to 11°C), profound (10 to 6°C), and ultra-profound (5 to 0°C) hypothermia. Protective hypothermia, induced before cardiac arrest, has to be differentiated from preservative hypothermia, induced during cardiac arrest treatment, and from resuscitative hypothermia, induced after successful resuscitation. Protective hypothermia is used in cardiac surgery and neurosurgery, but is clinically unrealistic in sudden cardiac death. This review will focus on a) preservative mild hypothermia during cardiac arrest treatment and b) resuscitative mild hypothermia after successful resuscitation in respect to its clinical application in the out-of-hospital setting.Preservative hypothermia can further be differentiated into the induction of hypothermia during ischemia (before initiation of resuscitation - or before reperfusion) and the induction of hypothermia during resuscitation.Research in myocytes showed that injury to cells not only occurs during ischemia itself, but mainly with reperfusion by initiating several casc
Therapeutic Hypothermia in Stroke and Traumatic Brain Injury  [PDF]
Alireza Faridar,Eric M. Bershad,Afshin A. Divani
Frontiers in Neurology , 2011, DOI: 10.3389/fneur.2011.00080
Abstract: Therapeutic hypothermia (TH) is considered to improve survival with favorable neurological outcome in the case of global cerebral ischemia after cardiac arrest and perinatal asphyxia. The efficacy of hypothermia in acute ischemic stroke (AIS) and traumatic brain injury (TBI), however, is not well studied. Induction of TH typically requires a multimodal approach, including the use of both pharmacological agents and physical techniques. To date, clinical outcomes for patients with either AIS or TBI who received TH have yielded conflicting results; thus, no adequate therapeutic consensus has been reached. Nevertheless, it seems that by determining optimal TH parameters and also appropriate applications, cooling therapy still has the potential to become a valuable neuroprotective intervention. Among the various methods for hypothermia induction, intravascular cooling (IVC) may have the most promise in the awake patient in terms of clinical outcomes. Currently, the IVC method has the capability of more rapid target temperature attainment and more precise control of temperature. However, this technique requires expertise in endovascular surgery that can preclude its application in the field and/or in most emergency settings. It is very likely that combining neuroprotective strategies will yield better outcomes than utilizing a single approach.
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