Abstract
BackgroundAlthough targeted temperature management (TTM) is recommended in comatose survivors after cardiac arrest (CA), the optimal method to deliver TTM remains unknown. We performed a meta-analysis to evaluate the effects of different TTM methods on survival and neurological outcome after adult CA.MethodsWe searched on the MEDLINE/PubMed database until 22 February 2019 for comparative studies that evaluated at least two different TTM methods in CA patients. Data were extracted independently by two authors. We used the Newcastle-Ottawa Scale and a modified Cochrane ROB tools for assessing the risk of bias of each study. The primary outcome was the occurrence of unfavorable neurological outcome (UO); secondary outcomes included overall mortality.ResultsOur search identified 6886 studies; 22 studies (n = 8027 patients) were included in the final analysis. When compared to surface cooling, core methods showed a lower probability of UO (OR 0.85 [95% CIs 0.75–0.96]; p = 0.008) but not mortality (OR 0.88 [95% CIs 0.62–1.25]; p = 0.21). No significant heterogeneity was observed among studies. However, these effects were observed in the analyses of non-RCTs. A significant lower probability of both UO and mortality were observed when invasive TTM methods were compared to non-invasive TTM methods and when temperature feedback devices (TFD) were compared to non-TFD methods. These results were significant particularly in non-RCTs.ConclusionsAlthough existing literature is mostly based on retrospective or prospective studies, specific TTM methods (i.e., core, invasive, and with TFD) were associated with a lower probability of poor neurological outcome when compared to other methods in adult CA survivors (CRD42019111021).
Highlights
Effective neuroprotective strategies are required to prevent or minimize the development of extended anoxic brain injury after cardiac arrest (CA) after the return of spontaneous circulation (ROSC) [1]
In 2002, two randomized clinical trials (RCTs) showed that temperature management (TTM) at 33 °C for 12–24 h was associated with a significantly higher proportion of patients achieving a favorable neurological outcome when compared to any temperature control [3,4,5]; more recently, a large Randomized clinical trial (RCT) showed that the target temperature during TTM could be either 33 °C or 36 °C, with an active temperature control required for all patients [6]
Significant delay to initiate TTM could negate the positive effects of such intervention, RCTs showed no benefits from early TTM initiation using cold intravenous fluids, either during cardiopulmonary resuscitation (CPR) or immediately after ROSC, when compared to in-hospital TTM implementation [7, 8]
Summary
Effective neuroprotective strategies are required to prevent or minimize the development of extended anoxic brain injury after cardiac arrest (CA) after the return of spontaneous circulation (ROSC) [1]. The optimal TTM duration remains unknown; while prolonged therapy up to 72 h is effective in newborns suffering from anoxic-hypoxic encephalopathy [9], TTM at 33 °C for 48 h did not significantly improve long-term neurological outcome when compared to 24 h duration in adult OHCA [10]. All these studies dealing with early or prolonged cooling strategies suffered from significant biases and might have been underpowered.
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