Abstract
BackgroundMild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). International guidelines strongly support initiating TH for all eligible individuals presenting with OHCA; however, the timing of cooling initiation remains uncertain. This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA.MethodsThe MEDLINE and Cochrane databases were searched from inception to October 2017. Inclusion criteria for full-text review included RCTs comparing pre-hospital TH with no pre-hospital TH after cardiac arrest, patients > 14 years of age with documented cardiac arrest from any rhythm, and outcome data that included survival to hospital discharge and temperature at hospital arrival. Results of retrieved studies were compared through meta-analysis using random effects modelling.ResultsA total of 10 trials comprising 4220 patients were included. There were no significant differences between the two arms for the primary outcome of neurological recovery (risk ratio [RR] 1.04, 95% CI 0.93–1.15) or the secondary outcome of survival to hospital discharge (RR 1.01, 95% CI 0.92–1.11). However, there was a significantly lower temperature at hospital arrival in patients receiving pre-hospital TH (mean difference − 0.83, 95% CI − 1.03 to − 0.63). Pre-hospital TH significantly increased the risk of re-arrest (RR 1.19, 95% CI 1.00 to 1.41). No survival differences were observed among subgroups of patients who received intra-arrest TH vs post-arrest TH or who had shockable vs non-shockable rhythms.ConclusionsPre-hospital TH after OHCA effectively decreases body temperature at the time of hospital arrival. However, it does not improve rates of survival with good neurological outcome or overall survival and is associated with increased rates of re-arrest.
Highlights
Mild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA)
Study selection Retrieved abstracts were assessed by two reviewers (PJL and DB) to evaluate whether they met the following inclusion criteria for full-text review: (1) Randomised controlled trial (RCT) evaluating pre-hospital TH vs no pre-hospital TH after cardiac arrest; (2) patients > 14 years of age; (3) patients with documented cardiac arrest from rhythms, including ventricular fibrillation (VF), ventricular tachycardia, pulseless electrical activity and asystole; and (4) outcome data that included survival to hospital discharge and temperature at hospital arrival
We summarized categorical data using the risk ratio (RR) according to the Mantel-Haenszel method and a random effects model [16]
Summary
Mild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA. Targeted temperature management (TTM) or mild therapeutic hypothermia (TH) has been shown to improve survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA) [1]. Multiple randomised controlled trial (RCTs) have investigated the safety and efficacy of pre-hospital TH; all have failed to provide strong evidence to Lindsay et al Critical Care (2018) 22:66 support its widespread adoption. Previous meta-analyses have failed to provide strong data to support recommendations, but these did not include the most recent large trials of pre-hospital cooling [9,10,11,12].
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