Advanced Life Support Task Force Research Articles

A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest.

The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.

Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the second annual summary of International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations that includes the most recent cardiopulmonary resuscitation science reviewed by the International Liaison Committee on Resuscitation. This summary addresses the role of antiarrhythmic drugs in adults and children and includes the Advanced Life Support Task Force and Pediatric Task Force consensus statements, which summarize the most recent published evidence and an assessment of the quality of the evidence based on Grading of Recommendations, Assessment, Development, and Evaluation criteria. The statements include consensus treatment recommendations approved by members of the relevant task forces. Insights into the deliberations of each task force are provided in the Values and Preferences and Task Force Insights sections. Finally, the task force members have listed the top knowledge gaps for further research.

Temperature management after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association

Temperature management after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association

Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.

For more than a decade, mild induced hypothermia (32 °C-34 °C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33 °C or 36 °C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32 °C and 36 °C for at least 24 hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document.

Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation

For more than a decade, mild induced hypothermia (32°C–34°C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33°C or 36°C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post–cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32°C and 36°C for at least 24hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document.

Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies 1 Institute of Medicine. Standards for systematic reviews. 2011 Google Scholar and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. 2 Schünemann H. Brożek J. Guyatt G. Oxman A. GRADE handbook. 2013 Google Scholar Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format) 3 O’Connor D. Green S. Higgins J.P.T. Chapter 5. Defining the review questions and developing criteria for including studies. in: The Cochrane Collaboration Higgins J. Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. 2011 Google Scholar were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).

Chest Compression Rate

The first description of modern cardiopulmonary resuscitation (CPR) included the instruction to compress the chest “about 60 times per minute”1; however, the optimal compression rate was unknown. Franz Koenig is credited with describing the original technique for external cardiac massage, which included a compression rate of 30 to 40 per minute.2 But in the first published description of external cardiac massage in 1892, Friedrich Maass documented a better clinical response with a rate of 120 per minute.2 To this day, the optimal compression rate is the subject of controversy. Animal data indicate that cardiac output increases with compression rates up to as high as 150 per minute.3 In a canine model of prolonged cardiac arrest, compression rates of 120 per minute compared with 60 per minute increased mean aortic (systolic and diastolic) and coronary perfusion pressures, and 24-hour survival (61% versus 15%, P =0.03).4 In a study of 9 patients undergoing CPR, a compression rate of 120 per minute generated higher aortic peak pressures and coronary perfusion pressures compared with a compression rate of 60 per minute (the rate recommended by the 1980 American Heart Association [AHA] guidelines). This evidence is supported by another study of 23 patients in cardiac arrest in which compressions at 120 per minute resulted in significantly higher end-tidal carbon dioxide values compared with compressions at 80 per minute.5 Article see p 3004 The first large, prospective, observational study of the influence of chest compression rate on patient survival was published in this journal in 2005.6 The number of delivered chest compressions was recorded by trained observers during in-hospital resuscitation attempts. A higher chest compression rate was associated with a higher rate of return of spontaneous circulation (ROSC). The mean chest compression rate for initial survivors was 90 …

Abstract 34: National Trends in Therapeutic Hypothermia, Mortality and Resource Utilization After Cardiac Arrest

Background: In 2002, the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation recommended the use of hypothermia in unconscious adult patients with out-of-hospital cardiac arrest. Since then, various retrospective and prospective studies have shown to improve outcomes with therapeutic hypothermia in select cases of cardiac arrest. Despite the evidence of benefit, it is a widely underutilized in US hospitals. We aimed to study 5-year trend in the use of therapeutic hypothermia in the US hospitals. We also studied trends in the outcome and resource utilization in cardiac arrest over the study period. Methods: We analyzed data for years 2005-2009 from the United States Nationwide Inpatient Sample which is a 20% stratified clustered sample of all non-federal hospital discharges. Using International Classification of Diseases-9 (ICD-9) codes, we identified cases with cardiac arrest (427.5) who underwent therapeutic hypothermia (99.81). Population estimates were obtained by complex sample analysis used for NIS design. Comparisons were made by using χ2 and student-t tests. Trend analysis was performed by univariate regression using the year as a predictor variable. Results: We included a total of 687211 cases of cardiac arrest, of which 3420 (0.498%) underwent therapeutic hypothermia. Patients with therapeutic hypothermia were less likely of female gender (36.7% vs. 45.6%, p<0.001) and were more likely to be younger (mean age: 59.9 vs. 65.8 years, p<0.001). Compared to White (0.59%), African-American (0.34%) and Hispanic (0.25%) patients had lower use of hypothermia (p<0.001). Patient who underwent hypothermia incurred higher inflation adjusted hospital charges (117119 vs. 90511 USD, p<0.001). The discharge survival rate was also higher in patients with hypothermia treatment (41.8% vs. 37.2%, p=0.015). There was a significant upward trend in utilization of therapeutic hypothermia and downward trend in inpatient mortality during the 5-year study period (figure). Conclusions: With accumulating evidence of benefits of therapeutic hypothermia after cardiac arrest, its utilization rate in US has gradually improved over last few years. Though this finding is encouraging, a substantial proportion of eligible patients do not receive this treatment. Downward trend of post-arrest mortality found in this study may be an indicator of improvements in advanced life support protocols over the years.

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Optimal Recovery from Cardiac Arrest: Implementation of a Therapeutic Hypothermia Program

Part 3: Evidence Evaluation Process

Part 3: Evidence Evaluation Process

Part 8: Advanced Life Support

Part 8: Advanced Life Support

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Part 4: Advanced Life Support

The topics reviewed by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force are grouped as follows: (1) causes and prevention, (2) airway and ventilation, (3) drugs and fluids given during cardiac arrest, (4) techniques and devices to monitor and assist the circulation, (5) periarrest arrhythmias, (6) cardiac arrest in special circumstances, (7) postresuscitation care, and (8) prognostication. Defibrillation topics are discussed in Part 3. The most important developments in advanced life support (ALS) since the last ILCOR review in 2000 include For many topics there were insufficient data with which to make firm treatment recommendations. The following interventions in particular need further research: Rescuers may be able to identify some noncardiac causes of arrest and tailor the sequence of attempted resuscitation. Most patients sustaining in-hospital cardiac arrest display signs of deterioration for several hours before the arrest. Early identification of these high-risk patients and the immediate arrival of …

Keeping cool in acute liver failure: Rationale for the use of mild hypothermia

Encephalopathy, brain edema and intracranial hypertension are neurological complications responsible for substantial morbidity/mortality in patients with acute liver failure (ALF), where, aside from liver transplantation, there is currently a paucity of effective therapies. Mirroring its cerebro-protective effects in other clinical conditions, the induction of mild hypothermia may provide a potential therapeutic approach to the management of ALF. A solid mechanistic rationale for the use of mild hypothermia is provided by clinical and experimental studies showing its beneficial effects in relation to many of the key factors that determine the development of brain edema and intracranial hypertension in ALF, namely the delivery of ammonia to the brain, the disturbances of brain organic osmolytes and brain extracellular amino acids, cerebro-vascular haemodynamics, brain glucose metabolism, inflammation, subclinical seizure activity and alterations of gene expression. Initial uncontrolled clinical studies of mild hypothermia in patients with ALF suggest that it is an effective, feasible and safe approach. Randomized controlled clinical trials are now needed to adequately assess its efficacy, safety, clinical impact on global outcomes and to provide the guidelines for its use in ALF.

Inducing hypothermia to decrease neurological deficit: literature review

This paper reports a literature review to examine the effectiveness of inducing hypothermia to decrease neurological deficit after out-of-hospital cardiac arrest. After cardiac arrest, severe neurological impairment is a major problem. Outcome after anoxic brain injury following cardiac arrest varies from normal function to brain death. However, a large proportion of these patients are left with severe disability and completely dependent on others for basic needs. Since the 1950s, several studies have shown how hypothermia can be neuroprotective. Recently, these studies have been taken to human trials in populations experiencing out-of-hospital cardiac arrest. A literature search was conducted using the Ovid and MDConsult databases for the years 1966-2004 and the keywords included hypothermia, therapeutic hypothermia, and cardiac arrest. Only English language papers were retrieved. Six human trials were found. All six studies showed improved neurological outcomes and four of these showed a decrease in mortality. Minimal complications exist from inducing mild hypothermia after cardiac arrest, and include decreased heart rate, increased systemic vascular resistance, transient electrolyte abnormalities (increased serum potassium and glucose), possible increase in pneumonia or other infectious processes, possible rebound hyperthermia, possible hypotension, and possible arrhythmias. Based on the review of these studies and the recommendations from the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation, advanced practice nurses should promote this practice, but look for further research on specific treatment recommendations.