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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024; 48:341-355. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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Taira T, Inoue A, Okamoto H, Maekawa K, Hifumi T, Sakamoto T, Kuroda Y, Suga M, Nishimura T, Ijuin S, Ishihara S. Fluid balance during acute phase extracorporeal cardiopulmonary resuscitation and outcomes in OHCA patients: a retrospective multicenter cohort study. Clin Res Cardiol 2024:10.1007/s00392-024-02444-z. [PMID: 38635032 DOI: 10.1007/s00392-024-02444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The association between fluid balance and outcomes in patients who underwent out-of-hospital cardiac arrest (OHCA) and received extracorporeal cardiopulmonary resuscitation (ECPR) remains unknown. We aimed to examine the above relationship during the first 24 h following intensive care unit (ICU) admission. METHODS We performed a secondary analysis of the SAVE-J II study, a retrospective multicenter study involving OHCA patients aged ≥ 18 years treated with ECPR between 2013 and 2018 and who received fluid therapy following ICU admission. Fluid balance was calculated based on intravenous fluid administration, blood transfusion, and urine output. The primary outcome was in-hospital mortality. The secondary outcomes included unfavorable outcome (cerebral performance category scores of 3-5 at discharge), acute kidney injury (AKI), and need for renal replacement therapy (RRT). RESULTS Overall, 959 patients met our inclusion criteria. In-hospital mortality was 63.6%, and the proportion of unfavorable outcome at discharge was 82.0%. The median fluid balance in the first 24 h following ICU admission was 3673 mL. Multivariable analysis revealed that fluid balance was significantly associated with in-hospital mortality (odds ratio (OR), 1.04; 95% confidence interval (CI), 1.02-1.06; p < 0.001), unfavorable outcome (OR, 1.03; 95% CI, 1.01-1.06; p = 0.005), AKI (OR, 1.04; 95% CI, 1.02-1.05; p < 0.001), and RRT (OR, 1.05; 95% CI, 1.03-1.07; p < 0.001). CONCLUSIONS Excessive positive fluid balance in the first day following ICU admission was associated with in-hospital mortality, unfavorable outcome, AKI, and RRT in ECPR patients. Further investigation is warranted.
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Affiliation(s)
- Takuya Taira
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan.
| | - Hiroshi Okamoto
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Masafumi Suga
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Shinichi Ijuin
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-Ku, Kobe, Hyogo, 651-0073, Japan
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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Behringer W, Böttiger BW, Biasucci DG, Chalkias A, Connolly J, Dodt C, Khoury A, Laribi S, Leach R, Ristagno G. Temperature control after successful resuscitation from cardiac arrest in adults: a joint statement from the European Society for Emergency Medicine (EUSEM) and the European Society of Anaesthesiology and Intensive Care (ESAIC). Eur J Emerg Med 2024; 31:86-89. [PMID: 38126247 PMCID: PMC10901227 DOI: 10.1097/mej.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Bernd W. Böttiger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Daniele G. Biasucci
- Department of Clinical Science and Translational Medicine, ‘Tor Vergata’ University of Rome, Rome, Italy
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Jim Connolly
- Accident and Emergency, Great North Trauma and Emergency Care, Newcastle-upon-Tyne, UK
| | - Christoph Dodt
- Department of Emergency Medicine, München Klinik, Munich, Germany
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon
| | - Said Laribi
- Department of Emergency Medicine, Tours University Hospital, Tours, France
| | - Robert Leach
- Department of Emergency Medicine, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Giuseppe Ristagno
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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van Diepen S, Le May MR, Alfaro P, Goldfarb MJ, Luk A, Mathew R, Peretz-Larochelle M, Rayner-Hartley E, Russo JJ, Senaratne JM, Ainsworth C, Belley-Côté E, Fordyce CB, Kromm J, Overgaard CB, Schnell G, Wong GC. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Clinical Practice Update on Optimal Post Cardiac Arrest and Refractory Cardiac Arrest Patient Care. Can J Cardiol 2024; 40:524-539. [PMID: 38604702 DOI: 10.1016/j.cjca.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 04/13/2024] Open
Abstract
Survival to hospital discharge among patients with out-of-hospital cardiac arrest (OHCA) is low and important regional differences in treatment practices and survival have been described. Since the 2017 publication of the Canadian Cardiovascular Society's position statement on OHCA care, multiple randomized controlled trials have helped to better define optimal post cardiac arrest care. This working group provides updated guidance on the timing of cardiac catheterization in patients with ST-elevation and without ST-segment elevation, on a revised temperature control strategy targeting normothermia instead of hypothermia, blood pressure, oxygenation, and ventilation parameters, and on the treatment of rhythmic and periodic electroencephalography patterns in patients with a resuscitated OHCA. In addition, prehospital trials have helped craft new expert opinions on antiarrhythmic strategies (amiodarone or lidocaine) and outline the potential role for double sequential defibrillation in patients with refractory cardiac arrest when equipment and training is available. Finally, we advocate for regionalized OHCA care systems with admissions to a hospital capable of integrating their post OHCA care with comprehensive on-site cardiovascular services and provide guidance on the potential role of extracorporeal cardiopulmonary resuscitation in patients with refractory cardiac arrest. We believe that knowledge translation through national harmonization and adoption of contemporary best practices has the potential to improve survival and functional outcomes in the OHCA population.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patricia Alfaro
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Maude Peretz-Larochelle
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Erin Rayner-Hartley
- Royal Columbian Hospital, Division of Cardiology, University of British Columbia, New Westminster, British Columbia, Canada
| | - Juan J Russo
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Janek M Senaratne
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Kromm
- Department of Critical Care, Department of Clinical Neurosciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gregory Schnell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Behringer W, Böttiger BW, Biasucci DG, Chalkias A, Connolly J, Dodt C, Khoury A, Laribi S, Leach R, Ristagno G. Temperature control after successful resuscitation from cardiac arrest in adults: A joint statement from the European Society for Emergency Medicine and the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2024; 41:278-281. [PMID: 38126249 PMCID: PMC10906202 DOI: 10.1097/eja.0000000000001948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
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Scquizzato T, Sandroni C, Soar J, Nolan JP. Top cardiac arrest randomised trials of 2023. Resuscitation 2024; 196:110133. [PMID: 38311283 DOI: 10.1016/j.resuscitation.2024.110133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/17/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Taccone FS, Dankiewicz J, Cariou A, Lilja G, Asfar P, Belohlavek J, Boulain T, Colin G, Cronberg T, Frat JP, Friberg H, Grejs AM, Grillet G, Girardie P, Haenggi M, Hovdenes J, Jakobsen JC, Levin H, Merdji H, Njimi H, Pelosi P, Rylander C, Saxena M, Thomas M, Young PJ, Wise MP, Nielsen N, Lascarrou JB. Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm: A Meta-Analysis. JAMA Neurol 2024; 81:126-133. [PMID: 38109117 PMCID: PMC10728804 DOI: 10.1001/jamaneurol.2023.4820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/06/2023] [Indexed: 12/19/2023]
Abstract
Importance International guidelines recommend body temperature control below 37.8 °C in unconscious patients with out-of-hospital cardiac arrest (OHCA); however, a target temperature of 33 °C might lead to better outcomes when the initial rhythm is nonshockable. Objective To assess whether hypothermia at 33 °C increases survival and improves function when compared with controlled normothermia in unconscious adults resuscitated from OHCA with initial nonshockable rhythm. Data Sources Individual patient data meta-analysis of 2 multicenter, randomized clinical trials (Targeted Normothermia after Out-of-Hospital Cardiac Arrest [TTM2; NCT02908308] and HYPERION [NCT01994772]) with blinded outcome assessors. Unconscious patients with OHCA and an initial nonshockable rhythm were eligible for the final analysis. Study Selection The study cohorts had similar inclusion and exclusion criteria. Patients were randomized to hypothermia (target temperature 33 °C) or normothermia (target temperature 36.5 to 37.7 °C), according to different study protocols, for at least 24 hours. Additional analyses of mortality and unfavorable functional outcome were performed according to age, sex, initial rhythm, presence or absence of shock on admission, time to return of spontaneous circulation, lactate levels on admission, and the cardiac arrest hospital prognosis score. Data Extraction and Synthesis Only patients who experienced OHCA and had a nonshockable rhythm with all causes of cardiac arrest were included. Variables from the 2 studies were available from the original data sets and pooled into a unique database and analyzed. Clinical outcomes were harmonized into a single file, which was checked for accuracy of numbers, distributions, and categories. The last day of follow-up from arrest was recorded for each patient. Adjustment for primary outcome and functional outcome was performed using age, gender, time to return of spontaneous circulation, and bystander cardiopulmonary resuscitation. Main Outcomes and Measures The primary outcome was mortality at 3 months; secondary outcomes included unfavorable functional outcome at 3 to 6 months, defined as a Cerebral Performance Category score of 3 to 5. Results A total of 912 patients were included, 490 from the TTM2 trial and 422 from the HYPERION trial. Of those, 442 had been assigned to hypothermia (48.4%; mean age, 65.5 years; 287 males [64.9%]) and 470 to normothermia (51.6%; mean age, 65.6 years; 327 males [69.6%]); 571 patients had a first monitored rhythm of asystole (62.6%) and 503 a presumed noncardiac cause of arrest (55.2%). At 3 months, 354 of 442 patients in the hypothermia group (80.1%) and 386 of 470 patients in the normothermia group (82.1%) had died (relative risk [RR] with hypothermia, 1.04; 95% CI, 0.89-1.20; P = .63). On the last day of follow-up, 386 of 429 in the hypothermia group (90.0%) and 413 of 463 in the normothermia group (89.2%) had an unfavorable functional outcome (RR with hypothermia, 0.99; 95% CI, 0.87-1.15; P = .97). The association of hypothermia with death and functional outcome was consistent across the prespecified subgroups. Conclusions and Relevance In this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- After ROSC Network
| | - Josef Dankiewicz
- Cardiology Department, Lund University, Skåne University Hospital Lund, Lund, Sweden
| | - Alain Cariou
- After ROSC Network
- Department of Intensive Care, Paris Cité University, Cochin Hospital (APHP), Paris, France
| | - Gisela Lilja
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Pierre Asfar
- Département de Médecine Intensive Réanimation, CHU Angers, Angers, France
| | - Jan Belohlavek
- 2nd Department of Medicine, Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional, d’Orléans, Hôpital de la Source, Orléans, France
| | - Gwenhael Colin
- District Hospital Center, Medical-Surgical Intensive Care Unit, La Roche-sur-Yon, France
| | - Tobias Cronberg
- Neurology Department of Clinical Sciences, Lund University, Lund, Sweden
- Neurology Department, Skåne University Hospital, Lund, Sweden
| | - Jean-Pierre Frat
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Hans Friberg
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
- Skåne University Hospital, Intensive and Perioperative Care, Malmö, Sweden
| | - Anders M. Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Patrick Girardie
- Médecine Intensive Réanimation, CHU Lille, Université de Lille, Faculté de Médicine, Lille, France
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Jan Hovdenes
- Department of Anesthesia and Intensive Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Helena Levin
- Department of Research & Education, Lund University and Skåne University Hospital, Lund, Sweden
| | - Hamid Merdji
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France
- INSERM, UMR 1260, Regenerative Nanomedicine, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg (UNISTRA), Strasbourg, France
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Paolo Pelosi
- Department of Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Manoj Saxena
- Critical Care and Trauma Division, George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, St George Hospital, Kogarah, New South Wales, Australia
| | - Matt Thomas
- Department of Anaesthesia, Southmead Hospital, Bristol, United Kingdom
| | - Paul J. Young
- Department of Intensive Care, Wellington Regional Hospital, Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Matt P. Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, United Kingdom
| | - Niklas Nielsen
- INSERM CIC 1402, groupe IS-ALIVE, Université de Poitiers, Poitiers, France
| | - Jean-Baptiste Lascarrou
- After ROSC Network
- Medecine Intensive Reanimation, CHU Nantes, Nantes, France
- Université Paris Cité, INSERM, PARCC, 75015 Paris, France
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Jiang L, Bian Y, Liu W, Zheng W, Zheng J, Li C, Lv R, Pan Y, Zheng Z, Wang M, Sang S, Pan C, Wang C, Liu R, Cheng K, Zhang J, Ma J, Chen Y, Xu F. TREATMENT OF COMATOSE SURVIVORS OF IN-HOSPITAL CARDIAC ARREST WITH EXTENDED ENDOVASCULAR COOLING METHOD FOR 72 H: A PROPENSITY SCORE-MATCHED ANALYSIS. Shock 2024; 61:204-208. [PMID: 38010311 DOI: 10.1097/shk.0000000000002276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
ABSTRACT Aims: Targeted temperature management is recommended for at least 24 h in comatose survivors of in-hospital cardiac arrest (IHCA) after the return of spontaneous circulation; however, whether an extension for 72 h leads to better neurological outcomes is uncertain. Methods: We included data from the Qilu Hospital of Shandong University between July 20, 2019, and June 30, 2022. Unconscious patients who had return of spontaneous circulation lasting >20 consecutive min and received endovascular cooling (72 h) or normothermia treatment were compared in terms of survival-to-discharge and favorable neurological survival. Propensity score matching was used to formulate balanced 1:3 matched patients. Results: In total, 2,084 patients were included. Sixteen patients received extended endovascular cooling and 48 matched controls received normothermia therapy. Compared with the normothermia group, patients who received prolonged endovascular cooling had a higher survival-to-discharge rate. However, good neurological outcomes did not differ significantly. Before matching, Cox regression analysis, using mortality as the event, showed that extended endovascular cooling independently affected the survival of IHCA patients. Conclusions: Among comatose patients who had been resuscitated from IHCA, the use of endovascular cooling for 72 h might confer a benefit on survival-to-discharge.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Shaowei Sang
- Shandong University Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, China
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Tan DJ, Chen J, Zhou Y, Ong JSQ, Sin RJX, Bui TV, Mehta AA, Feng M, See KC. Association of body temperature and mortality in critically ill patients: an observational study using two large databases. Eur J Med Res 2024; 29:33. [PMID: 38184625 PMCID: PMC10770998 DOI: 10.1186/s40001-023-01616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/23/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Body temperature (BT) is routinely measured and can be controlled in critical care settings. BT can impact patient outcome, but the relationship between BT and mortality has not been well-established. METHODS A retrospective cohort study was conducted based on the MIMIC-IV (N = 43,537) and eICU (N = 75,184) datasets. The primary outcome and exposure variables were hospital mortality and first 48-h median BT, respectively. Generalized additive models were used to model the associations between exposures and outcomes, while adjusting for patient age, sex, APS-III, SOFA, and Charlson comorbidity scores, temperature gap, as well as ventilation, vasopressor, steroids, and dialysis usage. We conducted subgroup analysis according to ICU setting, diagnoses, and demographics. RESULTS Optimal BT was 37 °C for the general ICU and subgroup populations. A 10% increase in the proportion of time that BT was within the 36-38 °C range was associated with reduced hospital mortality risk in both MIMIC-IV (OR 0.91; 95% CI 0.90-0.93) and eICU (OR 0.86; 95% CI 0.85-0.87). On the other hand, a 10% increase in the proportion of time when BT < 36 °C was associated with increased mortality risk in both MIMIC-IV (OR 1.08; 95% CI 1.06-1.10) and eICU (OR 1.18; 95% CI 1.16-1.19). Similarly, a 10% increase in the proportion of time when BT > 38 °C was associated with increased mortality risk in both MIMIC-IV (OR 1.09; 95% CI 1.07-1.12) and eICU (OR 1.09; 95% CI 1.08-1.11). All patient subgroups tested consistently showed an optimal temperature within the 36-38 °C range. CONCLUSIONS A BT of 37 °C is associated with the lowest mortality risk among ICU patients. Further studies to explore the causal relationship between the optimal BT and mortality should be conducted and may help with establishing guidelines for active BT management in critical care settings.
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Affiliation(s)
- Daniel J Tan
- Institute of Data Science, National University of Singapore, Singapore, Singapore
| | - Jiayang Chen
- National University Hospital, Singapore, Singapore
| | - Yirui Zhou
- School of Computing, National University of Singapore, Singapore, Singapore
| | | | | | - Thach V Bui
- Faculty of Engineering, National University of Singapore, Singapore, Singapore
| | | | - Mengling Feng
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
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12
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Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW. Corrigendum to "Temperature control after adult cardiac arrest: An updated systematic review and meta-analysis" [Resuscitation 191 (2023)109928]. Resuscitation 2024; 194:110052. [PMID: 38029469 DOI: 10.1016/j.resuscitation.2023.110052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Affiliation(s)
- Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Mathias J Holmberg
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark; Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
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13
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Busch HJ, Behringer W, Biever P, Böttiger BW, Eisenburger P, Fink K, Herkner H, Kreimeier U, Pin M, Wolfrum S. [Hypothermic temperature control after successful resuscitation of out-of-hospital cardiac arrest in adults : Statement from the resuscitation and postresuscitation treatment working groups of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) and the Austrian Association of Emergency Medicine (AAEM)]. Med Klin Intensivmed Notfmed 2023; 118:59-63. [PMID: 38051382 DOI: 10.1007/s00063-023-01092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/07/2023]
Abstract
In Germany per year approximately 60,000 and in Austria 5,000 adult patients suffer from out-of-hospital cardiac arrest. Only 10-15% of these patients survive without neurological damage. For decades hypothermic temperature control has been a central component of post-resuscitation treatment, but is controversial due to recently published studies.
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Affiliation(s)
- Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitätsnotfallzentrum, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität, Sir Hans-A-Krebs-Straße, 79180, Freiburg, Deutschland.
| | - Wilhelm Behringer
- Universitätsklinik für Notfallmedizin, MedUni Wien, Wien, Österreich
| | - Paul Biever
- Medizinische Interdisziplinäre Intensivtherapie Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Bernd W Böttiger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Köln, Deutschland
| | | | - Katrin Fink
- Zentrum für Notfall- und Rettungsmedizin, Universitätsnotfallzentrum, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität, Sir Hans-A-Krebs-Straße, 79180, Freiburg, Deutschland
| | - Harald Herkner
- Universitätsklinik für Notfallmedizin, MedUni Wien, Wien, Österreich
| | - Uwe Kreimeier
- Klinik für Anästhesiologie, LMU Klinikum, LMU München, München, Deutschland
| | - Martin Pin
- Zentrale Interdisziplinäre Notaufnahme und Akutstation, Florence-Nightingale-Krankenhaus, Kaiserswerther Diakonie, Düsseldorf, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
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14
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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15
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 368] [Impact Index Per Article: 368.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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16
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Macherey-Meyer S, Heyne S, Meertens MM, Braumann S, Hueser C, Mauri V, Baldus S, Lee S, Adler C. Restrictive versus high-dose oxygenation strategy in post-arrest management following adult non-traumatic cardiac arrest: a meta-analysis. Crit Care 2023; 27:387. [PMID: 37798666 PMCID: PMC10557287 DOI: 10.1186/s13054-023-04669-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE Neurological damage is the main cause of death or withdrawal of care in comatose survivors of cardiac arrest (CA). Hypoxemia and hyperoxemia following CA were described as potentially harmful, but reports were inconsistent. Current guidelines lack specific oxygen targets after return of spontaneous circulation (ROSC). OBJECTIVES The current meta-analysis assessed the effects of restrictive compared to high-dose oxygenation strategy in survivors of CA. METHODS A structured literature search was performed. Randomized controlled trials (RCTs) comparing two competing oxygenation strategies in post-ROSC management after CA were eligible. The primary end point was short-term survival (≤ 90 days). The meta-analysis was prospectively registered in PROSPERO database (CRD42023444513). RESULTS Eight RCTs enrolling 1941 patients were eligible. Restrictive oxygenation was applied to 964 patients, high-dose regimens were used in 977 participants. Short-term survival rate was 55.7% in restrictive and 56% in high-dose oxygenation group (8 trials, RR 0.99, 95% CI 0.90 to 1.10, P = 0.90, I2 = 18%, no difference). No evidence for a difference was detected in survival to hospital discharge (5 trials, RR 0.98, 95% CI 0.79 to 1.21, P = 0.84, I2 = 32%). Episodes of hypoxemia more frequently occurred in restrictive oxygenation group (4 trials, RR 2.06, 95% CI 1.47 to 2.89, P = 0.004, I2 = 13%). CONCLUSION Restrictive and high-dose oxygenation strategy following CA did not result in differences in short-term or in-hospital survival. Restrictive oxygenation strategy may increase episodes of hypoxemia, even with restrictive oxygenation targets exceeding intended saturation levels, but the clinical relevance is unknown. There is still a wide gap in the evidence of optimized oxygenation in post-ROSC management and specific targets cannot be concluded from the current evidence.
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Affiliation(s)
- S Macherey-Meyer
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - S Heyne
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - M M Meertens
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Center of Cardiology, Cardiology III -Angiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - S Braumann
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Hueser
- Faculty of Medicine and University Hospital Cologne, Clinic II for Internal Medicine, University of Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Emergency Department, University of Cologne, Cologne, Germany
| | - V Mauri
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Baldus
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - S Lee
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - C Adler
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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17
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Cotter EKH, Jacobs M, Jain N, Chow J, Estimé SR. Post-cardiac arrest care in the intensive care unit. Int Anesthesiol Clin 2023; 61:71-78. [PMID: 37678200 DOI: 10.1097/aia.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Elizabeth K H Cotter
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Jacobs
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Nisha Jain
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Jarva Chow
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
| | - Stephen R Estimé
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, Illinois
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18
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Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Andersen LW. Temperature control after adult cardiac arrest: An updated systematic review and meta-analysis. Resuscitation 2023; 191:109928. [PMID: 37558083 DOI: 10.1016/j.resuscitation.2023.109928] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Abstract
AIM To perform an updated systematic review and meta-analysis on temperature control in adult patients with cardiac arrest. METHODS The review is an update of a previous systematic review published in 2021. An updated search including PubMed, Embase, and the Cochrane Central Register of Controlled Trials was performed on May 31, 2023. Controlled trials in humans were included. The population included adult patients with cardiac arrest. The review included all aspects of temperature control including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE. RESULTS The updated systematic search identified six new trials. Risk of bias in the trials was assessed as intermediate for most of the outcomes. For temperature control with a target of 32-34 °C vs. normothermia or 36 °C, two new trials were identified, with seven trials included in an updated meta-analysis. Temperature control with a target of 32-34 °C did not result in an improvement in survival (risk ratio: 1.06 [95%CI: 0.91, 1.23]) or favorable neurological outcome (risk ratio: 1.27 [95%CI: 0.89, 1.81]) at 90-180 days after the cardiac arrest (low certainty evidence). Subgroup analysis according to location of cardiac arrest (in-hospital vs. out-of-hospital) found similar results. A sensitivity analysis of nine trials comparing temperature control at 32-34 °C to normothermia or 36 °C for favorable neurological outcome at any time point also did not show an improvement in outcomes (risk ratio: 1.14 [95%CI 0.98, 1.34]). New individual trials comparing a target of 31-34 °C, temperature control for 12-24 hours to 36 hours, a rewarming rate of 0.25-0.5 °C/hour, and the effect of temperature control with fever prevention found no differences in outcomes. CONCLUSIONS This updated systematic review showed no benefit of temperature control at 32-34 °C compared to normothermia or 36 °C, although the 95% confidence intervals cannot rule out a potential beneficial effect. Important knowledge gaps exist for topics such as hypothermic temperature targets, rewarming rate, and fever control.
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Affiliation(s)
- Asger Granfeldt
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark.
| | - Mathias J Holmberg
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry, United Kingdom; Royal United Hospital, Bath, United Kingdom
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Denmark; Department of Anesthesiology and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
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19
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Finkbeiner S, Fink K, Busch HJ. [Targeted temperature management after cardiac arrest]. Dtsch Med Wochenschr 2023; 148:1113-1117. [PMID: 37611576 DOI: 10.1055/a-1940-0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Actively avoiding fever is the only possibility to improve neurological outcome after cardiac arrest. It is uncertain if and which patients benefit from a lower target temperature. The ERC Guidelines in 2021 recommended targeted temperature management (TTM) for all patients after in- and out-of-hospital cardiac arrest with a target temperature of 32-36 °C for at least 24 hours. These recommendations were updated in 2022 by the ERC/ESICM Guidelines suggesting to avoid fever only within the first 72 hours after the event. Divergent results of recent trials lead to these guideline changes. The large TTM2 Trial in 2021 did not show a benefit neither in survival nor in neurological outcome in the group of hypothermia at 33°C compared to normothermia. Although leading to the updated guidelines, applying these study results to the German population is restricted as the rate of bystander cardiopulmonary resuscitation (CPR) or shockable rhythms is much lower in Germany. Further studies are needed to allow a better differentiation of subpopulations and to implement a more individual classification und therapy.
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Affiliation(s)
- Sandra Finkbeiner
- Zentrum für Notfall- und Rettungsmedizin, Universitätsklinikum Freiburg, Freiburg im Breisgau, Deutschland
| | - Katrin Fink
- Zentrum für Notfall- und Rettungsmedizin, Universitätsklinikum Freiburg, Freiburg im Breisgau, Deutschland
| | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitätsklinikum Freiburg, Freiburg im Breisgau, Deutschland
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20
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Taccone FS, Annoni F. Temperature management after cardiac arrest: what is next after the TTM-2 and BOX trials? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:504-506. [PMID: 37490845 DOI: 10.1093/ehjacc/zuad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070 Brussels, Belgium
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21
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Barros AJ, Enfield KB. In-Hospital Cardiac Arrest. Emerg Med Clin North Am 2023; 41:455-464. [PMID: 37391244 PMCID: PMC10549775 DOI: 10.1016/j.emc.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
This article reviews the epidemiology and management of in-hospital cardiac arrest.
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Affiliation(s)
- Andrew Julio Barros
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia School of Medicine, PO Box 800546, Charlottesville, VA 22908, USA.
| | - Kyle B Enfield
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia School of Medicine, PO Box 800546, Charlottesville, VA 22908, USA. https://twitter.com/KBEnfieldMD
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22
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Penketh J, Nolan JP. Post-Cardiac Arrest Syndrome. J Neurosurg Anesthesiol 2023; 35:260-264. [PMID: 37192474 DOI: 10.1097/ana.0000000000000921] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 04/06/2023] [Indexed: 05/18/2023]
Abstract
Post-cardiac arrest syndrome (PCAS) is a multicomponent entity affecting many who survive an initial period of resuscitation following cardiac arrest. This focussed review explores some of the strategies for mitigating the effects of PCAS following the return of spontaneous circulation. We consider the current evidence for controlled oxygenation, strategies for blood-pressure targets, the timing of coronary reperfusion, and the evidence for temperature control and treatment of seizures. Despite several large trials investigating specific strategies to improve outcomes after cardiac arrest, many questions remain unanswered. Results of some studies suggest that interventions may benefit specific subgroups of cardiac arrest patients, but the optimal timing and duration of many interventions remain unknown. The role of intracranial pressure monitoring has been the subject of only a few studies, and its benefits remain unclear. Research aimed at improving the management of PCAS is ongoing.
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Affiliation(s)
| | - Jerry P Nolan
- Intensive care unit, Royal United Hospital, Bath
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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23
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Chiu PY, Chung CC, Tu YK, Tseng CH, Kuan YC. Therapeutic hypothermia in patients after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Am J Emerg Med 2023; 71:182-189. [PMID: 37421815 DOI: 10.1016/j.ajem.2023.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/18/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) with therapeutic hypothermia (TH) has been used to improve neurological outcomes in patients after cardiac arrest; however, several trials have reported conflicting results regarding its effectiveness. This systematic review and meta-analysis assessed whether TH was associated with better survival and neurological outcomes after cardiac arrest. METHOD We searched online databases for relevant studies published before May 2023. Randomized controlled trials (RCTs) comparing TH and normothermia in post-cardiac-arrest patients were selected. Neurological outcomes and all-cause mortality were assessed as the primary and secondary outcomes, respectively. A subgroup analysis according to initial electrocardiography (ECG) rhythm was performed. RESULT Nine RCTs (4058 patients) were included. The neurological prognosis was significantly better in patients with an initial shockable rhythm after cardiac arrest (RR = 0.87, 95% confidence interval [CI] = 0.76-0.99, P = 0.04), especially in those with earlier TH initiation (<120 min) and prolonged TH duration (≥24 h). However, the mortality rate after TH was not lower than that after normothermia (RR = 0.91, 95% CI = 0.79-1.05). In patients with an initial nonshockable rhythm, TH did not provide significantly more neurological or survival benefits (RR = 0.98, 95% CI = 0.93-1.03 and RR = 1.00, 95% CI = 0.95-1.05, respectively). CONCLUSION Current evidence with a moderate level of certainty suggests that TH has potential neurological benefits for patients with an initial shockable rhythm after cardiac arrest, especially in those with faster TH initiation and longer TH maintenance.
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Affiliation(s)
- Po-Yun Chiu
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of General Medicine, Department of Medical Education, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chen-Chih Chung
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan
| | - Chien-Hua Tseng
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; Department of Neurology, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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Duhan S, Keisham B, Singh S, Rout A. Meta-Analysis Comparing Hypothermia Versus Normothermia in Patients After a Cardiac Arrest. Am J Cardiol 2023; 201:158-165. [PMID: 37385169 DOI: 10.1016/j.amjcard.2023.05.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023]
Abstract
The current American Heart Association 2022 guidelines recommend actively preventing fever by targeting a temperature ≤37.5°C for comatose patients after cardiac arrest. Contemporary randomized controlled trials (RCTs) show conflicting results regarding the benefit of targeted hypothermia (TH). We performed this updated meta-analysis of RCTs to evaluate the role of hypothermia in patients after a cardiac arrest. We searched Cochrane, MEDLINE, and EMBASE from inception to December 2022. Trials with patients randomly allocated for targeted temperature monitoring and reported neurologic and mortality outcomes were included. Statistical analysis was performed using Cochrane Review Manager using the random-effects model and calculated the pooled risk ratios of outcomes using the Mantel-Haenszel method. A total of 12 RCTs and 4,262 patients were included in the review. Compared with normothermia, the TH group had significantly improved neurologic outcomes (risk ratio 0.90, 95% confidence interval 0.83 to 0.98). However, no significant difference in mortality was observed (risk ratio 0.97, 95% confidence interval 0.90 to 1.06) between the groups. This meta-analysis supports the role of TH in patients after a cardiac arrest, especially secondary to improvement in neurologic outcomes.
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Affiliation(s)
- Sanchit Duhan
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Bijeta Keisham
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sahib Singh
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Amit Rout
- Department of Cardiology, University of Louisville, Louisville, Kentucky.
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Nielsen N, Friberg H. Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years: A Critical Care Perspective. Am J Respir Crit Care Med 2023; 207:1558-1564. [PMID: 37104654 DOI: 10.1164/rccm.202211-2142cp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
For 20 years, induced hypothermia and targeted temperature management have been recommended to mitigate brain injury and increase survival after cardiac arrest. On the basis of animal research and small clinical trials, the International Liaison Committee on Resuscitation strongly advocated hypothermia at 32-34 °C for 12-24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricular fibrillation or nonperfusing ventricular tachycardia. The intervention was implemented worldwide. In the past decade, hypothermia and targeted temperature management have been investigated in larger clinical randomized trials focusing on target temperature depth, target temperature duration, prehospital versus in-hospital initiation, nonshockable rhythms, and in-hospital cardiac arrest. Systematic reviews suggest little or no effect of delivering the intervention on the basis of the summary of evidence, and the International Liaison Committee on Resuscitation today recommends only to treat fever and keep body temperature below 37.5 °C (weak recommendation, low-certainty evidence). Here we describe the evolution of temperature management for patients with cardiac arrest during the past 20 years and how the accrued evidence has influenced not only the recommendations but also the guideline process. We also discuss possible paths forward in this field, bringing up both whether fever management is at all beneficial for patients with cardiac arrest and which knowledge gaps future clinical trials in temperature management should address.
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Affiliation(s)
- Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden; and
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Malmö, Sweden
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Zhu Md J, Zheng Md Z, Peng X. Letter by Zhu et al Regarding Article, "Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial". Circulation 2023; 147:1851. [PMID: 37307309 DOI: 10.1161/circulationaha.122.063485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Jianbing Zhu Md
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, China. Jiangxi Hypertension Research Institute, Nanchang, China
| | - Zeqi Zheng Md
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, China. Jiangxi Hypertension Research Institute, Nanchang, China
| | - Xiaoping Peng
- Department of Cardiology, The First Affiliated Hospital of Nanchang University, Nanchang, China. Jiangxi Hypertension Research Institute, Nanchang, China
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Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
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Roedl K, Kluge S. [Temperature management after cardiac arrest-a survey of clinical practice in Germany]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01008-9. [PMID: 37103524 DOI: 10.1007/s00063-023-01008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Kevin Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Penna A, Magliocca A, Merigo G, Stirparo G, Silvestri I, Fumagalli F, Ristagno G. One-Year Review in Cardiac Arrest: The 2022 Randomized Controlled Trials. J Clin Med 2023; 12:jcm12062235. [PMID: 36983236 PMCID: PMC10054058 DOI: 10.3390/jcm12062235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Cardiac arrest, one of the leading causes of death, accounts for numerous clinical studies published each year. This review summarizes the findings of all the randomized controlled clinical trials (RCT) on cardiac arrest published in the year 2022. The RCTs are presented according to the following categories: out-of- and in-hospital cardiac arrest (OHCA, IHCA) and post-cardiac arrest care. Interestingly, more than 80% of the RCTs encompassed advanced life support and post-cardiac arrest care, while no studies focused on the treatment of IHCA, except for one that, however, explored the temperature control after resuscitation in this population. Surprisingly, 9 out of 11 RCTs led to neutral results demonstrating equivalency between the newly tested interventions compared to current practice. One trial was negative, showing that oxygen titration in the immediate pre-hospital post-resuscitation period decreased survival compared to a more liberal approach. One RCT was positive and introduced new defibrillation strategies for refractory cardiac arrest. Overall, data from the 2022 RCTs discussed here provide a solid basis to generate new hypotheses to be tested in future clinical studies.
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Affiliation(s)
- Alessio Penna
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Aurora Magliocca
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Mario Negri Institute for Pharmacological Researches IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Giulia Merigo
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Giuseppe Stirparo
- Agenzia Regionale Emergenza Urgenza (AREU), Via Campanini 6, 20124 Milan, Italy
| | - Ivan Silvestri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Francesca Fumagalli
- Mario Negri Institute for Pharmacological Researches IRCCS, Via Mario Negri 2, 20156 Milan, Italy
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122 Milan, Italy
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy
- Correspondence:
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Matsumoto S, Kuno T, Mikami T, Takagi H, Ikeda T, Briasoulis A, Bortnick AE, Sims D, Katz JN, Jentzer J, Bangalore S, Alviar CL. Effect of cooling methods and target temperature on outcomes in comatose patients resuscitated from cardiac arrest: Systematic review and network meta-analysis of randomized trials. Am Heart J 2023; 256:73-84. [PMID: 36372248 DOI: 10.1016/j.ahj.2022.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been recommended after cardiac arrest (CA), however the specific temperature targets and cooling methods (intravascular cooling (IVC) versus surface cooling (SC)) remain uncertain. METHODS PUBMED and EMBASE were searched until October 8, 2022 for randomized clinical trials (RCTs) investigating the efficacy of TTM after CA. The randomized treatment arms were categorized into the following 6 groups: 31..C to 33..C IVC, 31..C to 33..C SC, 34..C to 36..C IVC, 34..C to 36..C SC, strict normothermia or fever prevention (Strict NT or FP), and standard of care without TTM (No-TTM). The primary outcome was neurological recovery. P-score was used to rank the treatments, where a larger value indicates better performance. RESULTS We identified 15 RCTs, involving 5,218 patients with CA. Compared to No-TTM as the reference, the other therapeutic options significantly improved neurological outcomes (vs No-TTM; 31..C to 33.. C IVC RR = 0.67, 95% CI 0.54 to 0.83; 31..C to 33..C SC RR = 0.73, 95% CI 0.61 to 0.87; 34..C to 36.. C IVC RR = 0.66, 95% CI 0.51 to 0.86; 34..C to 36..C SC: RR = 0.73, 0.59 to 0.90; Strict NT or FP: RR = 0.75, 95% CI 0.62 to 0.90). Overall, 31-33..C IVC had the highest probability to be the best therapeutic option to improve outcomes (the ranking P-score of 0.836). As a subgroup analysis, the ranking P-score showed that IVC might be a better cooling method compared to SC (IVC vs SC P-score: 0.960 vs 0.670). CONCLUSIONS Hypothermia (31..C to 36..C IVC and SC) and active normothermia (Strict-NT and Strict-FP) were associated with better neurological outcomes compared to No-TTM, with IVC having a greater probability of being the better cooling method than SC.
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Affiliation(s)
- Shingo Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY.
| | | | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takanori Ikeda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Anna E Bortnick
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Daniel Sims
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Jason N Katz
- Division of Cardiovascular Medicine, Duke University, Durham, NC
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sripal Bangalore
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
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Roedl K, Wolfrum S, Michels G, Pin M, Söffker G, Janssens U, Kluge S. Temperature control in adults after cardiac arrest: a survey of current clinical practice in Germany. Crit Care 2023; 27:35. [PMID: 36691075 PMCID: PMC9869510 DOI: 10.1186/s13054-023-04319-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/11/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Temperature control is recommended after out of hospital cardiac arrest (OHCA) by international guidelines. This survey aimed to investigate current clinical practice and areas of uncertainty. METHODS Online survey targeting members of three medical emergency and critical care societies in Germany (April 21-June 6, 2022) assessing post-cardiac arrest temperature control management. RESULTS Of 341 completed questionnaires 28% (n = 97) used temperature control with normothermic target and 72% (n = 244) temperature control with hypothermic target. The definition of fever regarding patients with cardiac arrest ranged from ≥ 37.7 to 39.0 °C. Temperature control was mainly started in the ICU (80%, n = 273) and most commonly core cooling (74%, n = 254) and surface cooling (39%, n = 134) with feedback were used. Temperature control was maintained for 24 h in 18% (n = 61), 48 h in 28% (n = 94), 72 h in 42% (n = 143) and longer than 72 h in 13% (n = 43). 7% (n = 24) were using different protocols for OHCA with initial shockable and non-shockable rhythm. Additional 14% (n = 48) were using different temperature control protocols after in-hospital cardiac arrest (IHCA) compared with OHCA. Overall, 37% (n = 127) changed practice after the publication of the ERC-2021 guidelines and 33% (n = 114) after the recent publication of the revised ERC-ESICM guideline on temperature control. CONCLUSIONS One-third of the respondents changed clinical practice since recent guideline update. However, a majority of physicians further trusts in temperature control with a hypothermic target. Of interest, 14% used different temperature control strategies after IHCA compared with OHCA and 7% for shockable and non-shockable initial rhythm. A more individualized approach in post resuscitation care may be warranted.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | | | - Guido Michels
- Department of Acute and Emergency Care, St.-Antonius-Hospital, Eschweiler, Germany
| | - Martin Pin
- Emergency Department, Florence-Nightingale Hospital, Duesseldorf, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St.-Antonius Hospital, Eschweiler, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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32
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Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Integrating Evidence Into Real World Practice. Can J Cardiol 2023; 39:385-393. [PMID: 36610519 DOI: 10.1016/j.cjca.2022.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been a focus of debate in an attempt to improve post-arrest outcomes. Contemporary trials examining the role of TTM after cardiac arrest suggest that targeting normothermia should be the standard of care for initially comatose survivors of cardiac arrest. Differences in patient populations have been demonstrated across trials, and important subgroups may be under-represented in clinical trials compared with real-world registries. In this review, we aimed to describe the populations represented in international OHCA registries and to propose a pathway to integrate clinical trial evidence into practice. The patient case mix among registries including survivors to hospital admission was similar to the pivotal trials (shockable rhythm, witnessed arrest), suggesting reasonable external validity. Therefore, for the majority of OHCA, targeted normothermia should be the strategy of choice. There remains conflicting evidence for patients with a nonshockable rhythm, with no clear evidence-based justification for mild hypothermia over targeted normothermia.
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Kletečka J, Zatloukal J, Smékalová O, Beneš J. Year 2022 in Review - Intensive care medicine - Cardiovascular and general issues. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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34
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Cassara CM, Long MT, Dollerschell JT, Chae F, Hall DJ, Demiralp G, Stampfl MJ, Bernardoni B, McCarthy DP, Glazer JM. Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program. Medicina (B Aires) 2022; 58:medicina58121815. [PMID: 36557017 PMCID: PMC9781756 DOI: 10.3390/medicina58121815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.
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Affiliation(s)
- Chris M. Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-8100
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - John T. Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Floria Chae
- Department of Anesthesiology, Ohio State University Wexner Medical Center, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - David J. Hall
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Matthew J. Stampfl
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Brittney Bernardoni
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Daniel P. McCarthy
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
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Sandroni C, Natalini D, Nolan JP. Temperature control after cardiac arrest. Crit Care 2022; 26:361. [PMID: 36434649 PMCID: PMC9700892 DOI: 10.1186/s13054-022-04238-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/27/2022] Open
Abstract
Most of the patients who die after cardiac arrest do so because of hypoxic-ischemic brain injury (HIBI). Experimental evidence shows that temperature control targeted at hypothermia mitigates HIBI. In 2002, one randomized trial and one quasi-randomized trial showed that temperature control targeted at 32-34 °C improved neurological outcome and mortality in patients who are comatose after cardiac arrest. However, following the publication of these trials, other studies have questioned the neuroprotective effects of hypothermia. In 2021, the largest study conducted so far on temperature control (the TTM-2 trial) including 1900 adults comatose after resuscitation showed no effect of temperature control targeted at 33 °C compared with normothermia or fever control. A systematic review of 32 trials published between 2001 and 2021 concluded that temperature control with a target of 32-34 °C compared with fever prevention did not result in an improvement in survival (RR 1.08; 95% CI 0.89-1.30) or favorable functional outcome (RR 1.21; 95% CI 0.91-1.61) at 90-180 days after resuscitation. There was substantial heterogeneity across the trials, and the certainty of the evidence was low. Based on these results, the International Liaison Committee on Resuscitation currently recommends monitoring core temperature and actively preventing fever (37.7 °C) for at least 72 h in patients who are comatose after resuscitation from cardiac arrest. Future studies are needed to identify potential patient subgroups who may benefit from temperature control aimed at hypothermia. There are no trials comparing normothermia or fever control with no temperature control after cardiac arrest.
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Affiliation(s)
- Claudio Sandroni
- grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy ,grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy ,grid.8142.f0000 0001 0941 3192Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart. Fondazione ‘Policlinico Universitario A. Gemelli’ IRCCS. L.go F, Vito 1, 00168 Rome, Italy
| | - Daniele Natalini
- grid.414603.4Department of Intensive Care, Emergency Medicine, and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS. Largo A. Gemelli 8, 00168 Rome, Italy
| | - Jerry P. Nolan
- grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, Warwick Medical School, Warwick University, Gibbet Hill, Coventry, CV4 7AL UK ,grid.416091.b0000 0004 0417 0728Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG UK
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