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Abstract
BackgroundRandomized trials have shown that trans-nasal evaporative cooling initiated during CPR (i.e. intra-arrest) effectively lower core body temperature in out-of-hospital cardiac arrest patients. However, these trials may have been underpowered to detect significant differences in neurologic outcome, especially in patients with initial shockable rhythm.MethodsWe conducted a post hoc pooled analysis of individual data from two randomized trials including 851 patients who eventually received the allocated intervention and with available outcome (“as-treated” analysis). Primary outcome was survival with favourable neurological outcome at hospital discharge (Cerebral Performance Category [CPC] of 1–2) according to the initial rhythm (shockable vs. non-shockable). Secondary outcomes included complete neurological recovery (CPC 1) at hospital discharge.ResultsAmong the 325 patients with initial shockable rhythms, favourable neurological outcome was observed in 54/158 (34.2%) patients in the intervention and 40/167 (24.0%) in the control group (RR 1.43 [confidence intervals, CIs 1.01–2.02]). Complete neurological recovery was observed in 40/158 (25.3%) in the intervention and 27/167 (16.2%) in the control group (RR 1.57 [CIs 1.01–2.42]). Among the 526 patients with initial non-shockable rhythms, favourable neurological outcome was in 10/259 (3.8%) in the intervention and 13/267 (4.9%) in the control group (RR 0.88 [CIs 0.52–1.29]; p = 0.67); survival and complete neurological recovery were also similar between groups. No significant benefit was observed for the intervention in the entire population.ConclusionsIn this pooled analysis of individual data, intra-arrest cooling was associated with a significant increase in favourable neurological outcome in out-of-hospital cardiac arrest patients with initial shockable rhythms. Future studies are needed to confirm the potential benefits of this intervention in this subgroup of patients.
Highlights
Out-of-hospital cardiac arrest (OHCA) is one of the major health issues of the industrialized world [1]
Additional subgroup analyses did not show any statistical differences (Additional file 4: Fig. S3). In this pooled analysis of individual patient level data obtained from two randomized studies on the use of intra-arrest trans-nasal evaporative cooling in OHCA patients at the scene of the arrest compared to Targeted temperature management (TTM) initiated after hospital arrival, we showed that the intra-arrest cooling was associated with a significantly higher proportion of favourable neurological outcome at hospital discharge in patients with an initial shockable rhythm
A recent randomized study showed that TTM was effective among selected comatose survivors after cardiac arrest with non-shockable rhythm when compared to targeted normothermia [7], no effect of intra-arrest cooling was observed in patients with non-shockable rhythms in this pooled analysis
Summary
Out-of-hospital cardiac arrest (OHCA) is one of the major health issues of the industrialized world [1]. In 2002, two randomized clinical trials (RCTs) demonstrated the benefit of TTM on favourable neurologically recovery in patients who were cooled in hospital for 12–24 h to 32–34 °C following an out-of-hospital cardiac arrest with an initial shockable rhythm (i.e. ventricular fibrillation or pulseless ventricular tachycardia) [4, 5]. Randomized trials have shown that trans-nasal evaporative cooling initiated during CPR (i.e. intraarrest) effectively lower core body temperature in out-of-hospital cardiac arrest patients. These trials may have been underpowered to detect significant differences in neurologic outcome, especially in patients with initial shockable rhythm
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