Abstract
Targeted temperature management (TTM) is a complex intervention used with the aim of minimizing post-anoxic injury and improving neurological outcome after cardiac arrest. There is large variability in the devices used to achieve cooling and in protocols (e.g., for induction, target temperature, maintenance, rewarming, sedation, management of post-TTM fever). This variability can explain the limited benefits of TTM that have sometimes been reported. We therefore propose the concept of “high-quality TTM” as a way to increase the effectiveness of TTM and standardize its use in future interventional studies.
Highlights
Post-anoxic brain damage is the most dramatic complication of cardiac arrest [1]
Two early randomized clinical trials (RCTs) showed that temperature management (TTM) at 33 °C for 12–24 h was associated with a greater proportion of survivors with intact neurological recovery compared to standard care in of-hospital cardiac arrest (OHCA) survivors with witnessed shockable rhythm [4, 5], but subsequent observational studies questioned the efficacy of this intervention in other settings, such as nonshockable rhythms and in-hospital cardiac arrest (IHCA) [6, 7]
Many “supporters” of TTM criticized the “TTM trial” [8], emphasizing that a number of features, including the high patient heterogeneity, the very short time to resuscitation, the slow induction phase of TTM, and the rapid rewarming period, may have influenced the main results, and still consider TTM at 33 °C as the best therapeutic option in cardiac arrest survivors. This position is supported by the publication of the recent HYPERION study, which showed a significant improvement in neurological outcome at 3 months for patients with OHCA or IHCA associated with a non-shockable initial rhythm who were treated with TTM at 33 °C, compared to a control group kept at 37 °C [11]
Summary
Post-anoxic brain damage is the most dramatic complication of cardiac arrest [1]. In international guidelines, targeted temperature management (TTM) is the only neuroprotective intervention currently recommended after out-of-hospital cardiac arrest (OHCA) [2]. This position is supported by the publication of the recent HYPERION study, which showed a significant improvement in neurological outcome at 3 months for patients with OHCA or IHCA associated with a non-shockable initial rhythm who were treated with TTM at 33 °C, compared to a control group kept at 37 °C [11].
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