Differential Effect of Targeted Temperature Management Between 32 °C and 36 °C Following Cardiac Arrest According to Initial Severity of Illness: Insights From Two International Data Sets

BACKGROUND

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

RESEARCH QUESTION

Is there an association between the use of TTM32-36 and outcome according to severity assessed at ICU admission using a previously derived risk score?

STUDY DESIGN AND METHODS

Data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (France) between May 2011 and December 2017 and in the Resuscitation Outcomes Consortium Continuous Chest Compressions (ROC-CCC) trial (United States and Canada) between June 2011 and May 2015 were used for this study. Severity at ICU admission was assessed through a modified version of the Cardiac Arrest Hospital Prognosis (mCAHP) score, divided into tertiles of severity. The study explored associations between TTM32-36 and favorable neurologic status at hospital discharge by using multiple logistic regression as well as in tertiles of severity for each data set.

RESULTS

A total of 2,723 patients were analyzed in the SDEC data set and 4,202 patients in the ROC-CCC data set. A favorable neurologic status at hospital discharge occurred in 728 (27%) patients in the French data set and in 1,239 (29%) patients in the North American data set. Among the French data set, TTM32-36 was independently associated with better neurologic outcome in the tertile of patients with low (adjusted OR, 1.63; 95% CI, 1.15-2.30; P = .006) and high (adjusted OR, 1.94; 95% CI, 1.06-3.54; P = .030) severity according to mCAHP at ICU admission. Similar results were observed in the North American data set (adjusted ORs of 1.36 [95% CI, 1.05-1.75; P = .020] and 2.42 [95% CI, 1.38-4.24; P = .002], respectively). No association was observed between TTM32-36 and outcome in the moderate groups of the two data sets.

INTERPRETATION

TTM32-36 was significantly associated with a better outcome in patients with low and high severity at ICU admission assessed according to the mCAHP score. Further studies are needed to evaluate individualized temperature control following out-of-hospital cardiac arrest.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.

P2823Lack of early systematic investigations among young victims of sudden cardiac arrest

Introduction

Since a large proportion of patients resuscitated from out-of-hospital sudden cardiac arrest (SCA) die in the intensive care unit (ICU), early systematic investigation towards identifying etiology may be crucial to ensure targeted therapy and appropriate future prevention among relatives, especially when the index case is young.

Purpose

We hypothesized that etiologic investigations were not initiated in a timely manner in a significant proportion of young SCA patients, alive at ICU admission, prior to death.

Methods

In this prospective, ongoing, multicenter, population-based registry (6.7 million inhabitants), data from all SCA over a 5-year period were analyzed, in collaboration with all the 48 hospitals of the area, with a specific focus on young patients (<45 year-old) alive at hospital admission and who eventually died prior to ICU discharge. Investigations performed and diagnoses arrived at were analyzed from the medical records by two cardiologists for each case.

Results

Of the 18,622 out-of-hospital cardiac arrests from May 2011 to May 2016, 3,028 were admitted alive to ICU. Among them, 2,190 (72.3%) died in ICU, including 367 (16.8%) young cases (<45 yo). Among the young patients, while 163 cases (44.4%) had a specific diagnosis established, 204 (55.6%) remained unexplained. Coronary angiograms (18.3%), CT scan (brain and chest) (24.5%), and transthoracic echocardiography (29.1%) were all underutilized. Main established SCA causes were acute coronary syndrome (44.5%), followed by structural non-ischemic heart disease (25.5%), pulmonary embolism (13.6%), chronic CAD (10%), non-structural heart disease (1.8%) and miscellaneous (4.6%). The proportion of systematic autopsy (10.9%), as well as blood sample collection for further genetic testing (1.4%) was low. Information on family screening was rarely provided in the ICU.

Conclusion

More than half of young SCA cases who died in ICU remained unexplained. There was significant underuse of core cardiac investigations. Efforts to promote prompt and systematic investigation through better collaboration between intensivist and cardiologist may improve both acute management and future targeted preventive strategies for family members.

[Palliative care in delivery room for preterm infants less than 24 weeks of gestation. Analysis of two different behaviors]

AIMS OF THE STUDY

To describe the management of extremely preterm newborns at the threshold of viability before 24 weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered.

METHOD

A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed.

RESULTS

In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide.

CONCLUSION

At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital.

Post mortem scientific sampling and the search for causes of death in intensive care: what information should be given and what consent should be obtained?

PURPOSE

The search for cause of death is important to improve knowledge and provide answers for the relatives of the deceased. Medical autopsy following unexplained death in hospital is one way to identify cause of death but is difficult to carry out routinely. Post mortem sampling (PMS) of tissues via thin biopsy needle or 'mini incisions' in the skin may be a useful alternative. A study was undertaken to assess how this approach is perceived by intensive care doctors and also to evaluate how this practice is considered in ethical terms in France.

METHODS

A study of PMS practices immediately after death in 10 intensive care departments was performed. The medical director of each centre was interviewed by telephone and asked to describe practices in their unit and to outline the questions raised by this practice.

RESULTS

PMS is routinely performed in 70% of the units which responded, without systematically obtaining formal consent and without precise rules for communicating results. Approaches to PMS differed between centres, but all physicians felt that PMS is useful for the scientific information it gives and also for the information it provides for relatives. All physicians regret the lack of standards to structure PMS practices.

CONCLUSION

Information from post mortem examinations is important for society to inform about causes of death, for doctors to improve practices and for decision-makers responsible for organising care. Debate persists regarding the balance between individual rights and community interests. It is suggested that an approach for identifying cause of death could easily be integrated into the relationship between carers and relatives, provided full transparency is maintained.

Ethical issues arising from the requirement to sign a consent form in palliative care

French healthcare networks aim to help healthcare workers to take care of patients by improving cooperation, coordination and the continuity of care. When applied to palliative care in the home, they facilitate overall care including medical, social and psychological aspects. French legislation in 2002 required that an information document explaining the functioning of the network should be given to patients when they enter a healthcare network. The law requires that this document be signed. Ethical issues arise from this legislation with regard to the validity of the signature of dying patients. Signature of the consent form by a guardian or trustee, a designated person--the Person of Trust--transforms the doctor-patient relationship into a triangular doctor-patient-third-party relationship.

Ethical issues arising from the requirement to provide written information in palliative care

French Healthcare Networks aim to help healthcare workers take care of patients by improving co-operation, co-ordination and the continuity of care. When applied to palliative care in the home, they facilitate overall care, including medical, social and psychological aspects. French legislation in 2002 required that an information document explaining the functioning of the Network should be given to patients when they enter a Healthcare Network. Ethical problems arise from this legislation with regard to providing terminal patients with explicit information upon their entry into the palliative phase of the disease, and requiring them to sign the document. It highlights the limitations of this practice, and the gap between the legislation and the nature of the physician-patient relationship in palliative care.

Concerning mistreatment of older people: Clinical and ethical thoughts based on a study of known cases

Following a report by the Health Ministry recommending a greater implication of general practitioners (GP) in the diagnosis and care of mistreated older people, we wanted to evaluate what was actually their role in this matter. A study was made of files of mistreated older persons referred to the social services in a Parisian suburb. For each file, we noted who raised the first suspicions of mistreatment, who diagnosed it, what happened next, and what precisely the GP's role was. Out of 600 files, we found 12 cases, concerning 14 persons (two couples). Although all the patients had health problems requiring frequent consultations with their GP, none of these situations were diagnosed by the GP. In all cases, the GP played only a secondary role, if at all. The following points are discussed: The link between family problems and history cannot be ignored in the follow up of such situations. The GP's role is discussed regarding clinical knowledge of mistreatment and the legal rules they have to deal with. Our results bring to light how the balance between the person's autonomy and the necessary direct action is especially delicate in this field.