Arrest Therapeutic Hypothermia Research Articles

P0250COLD DIURESIS DURING TARGETED TEMPERATURE MANAGEMENT AFTER CARDIAC ARREST, MYTH OR FACT?

Abstract Background and Aims Therapeutic hypothermia or targeted temperature management (TTM) has been standard treatment for cardiac arrest survivors with suspected hypoxic ischemic brain injury for improvement in both survival and neurological outcomes. TTM is consisted of an induction phase of quickly lowering the temperature to target temperature (ranging from 32°C -36°C) as soon as possible, a hypothermia maintenance phase of keeping the body temperature at target temperature for at least 24 hours, a rewarming phase of slowly rewarming the temperature to normothermia, and a normothermia phase of keeping the body temperature at normothermia. During the dynamic changes in body temperature, cold-diuresis is a commonly described phenomenon. However, limited studies have characterized cold-induced diuresis during TTM. In this study, we sought to determine urine output changes during post cardiac arrest therapeutic hypothermia. Method This retrospective cohort study included adult patients who underwent TTM after out-of-hospital cardiac arrest and were admitted to the intensive care unit for post cardiac arrest care between January 2012 and August 2018. The exclusion criteria of this study were as follows: 1) deceased status before the completion of all phase of TTM; 2) previous end stage kidney disease patients, 3) undergoing renal replacement therapy due to AKI within 48 hours of TTM termination; 4) terminal cancer less than 6 months of life expectancy or previously cerebral performance category (CPC) 3 or more. The neurologic outcome was assessed using the CPC score after 1 month. Good neurologic outcome was defined as a CPC score of 1, 2 and poor neurologic outcome as a CPC score of 3 to 5. The post cardiac arrest protocol recommends a target temperature of 33°C unless the patient is hemodynamically unstable or has a bleeding tendency or severe infection. Rewarming rate was 0.15°C/hr or 0.25°C/hr. TTM was conducted with the use of temperature managing devices with a feedback loop system (Artic Sun Energy Transfer Pads, Medivance Corp., Louisville, CO, USA; Cool Guard Alsius Icy Heat Exchange Catheter, Alsius Corporation, Irvine, CA, USA). We calculated the hourly IV fluid input and urine output rates for each TTM phase. To compare the mean of urine volume between each TTM phase, we used repeated measure analysis of variance (ANOVA). Results 178 Patients included in the analysis. We observed a increase in urine output rates during hypothermia induction. This effect persisted even after adjustment for variable clinical confounders, including intravenous fluid input rate, mean arterial pressure (MAP), initial shockable rhythm, SOFA score, body mass index, and IV furosemide use. However, we did not detect any evidence of urine output increases or decreases during the hypothermia maintenance or rewarming phases. By repeating measures ANOVA and a linear mixed model, it was confirmed that there is a difference in urine output for each TTM phase. Even after the post hoc analysis was calibrated with several variables, only the hypotheria induction phase differed significantly from the urine output of the phase. Conclusion Although our results are some limitations, the findings support the potential presence of cold-induced dieresis, but not rewarm anti-diuresis during TTM. Our study may not fully capture the extent of renal impairment in post cardiac arrest undergoing TTM. However, our objective was to characterize urine output during TTM in post cardiac arrest patients. This has important implications for fluid management in patients undergoing TTM.

EEG Characteristics in Cooled and Rewarmed Periods in Post-cardiac Arrest Therapeutic Hypothermia Patients: Erratum.

EEG Characteristics in Cooled and Rewarmed Periods in Post-cardiac Arrest Therapeutic Hypothermia Patients: Erratum.

EEG Characteristics in Cooled and Rewarmed Periods in Post-cardiac Arrest Therapeutic Hypothermia Patients.

Continuous video EEG is a tool to assess brain function in injuries, including cardiac arrest (CA). In post-CA therapeutic hypothermia (TH) studies, some EEG features are linked to poor prognosis, but the evolvement of EEG characteristics during two temperature phases and its significance is unclear. We systematically analyzed EEG characteristics in cooled and rewarmed phases of post-CA therapeutic hypothermia patients and investigated their correlation to patient outcome. This is a retrospective study of EEG analyses, from a single academic center, of 20 patients who underwent CA and therapeutic hypothermia. For each patient, three 30-minute EEG segments in cooled and rewarmed phases were analyzed for continuity, frequency, interictal epileptiform discharges, and seizures. Mortality at the time of discharge was used as outcome. Rewarming was associated with the emergence of interictal epileptiform discharges, 2.6 times as likely compared with the cooled period (P = 0.03), and was not affected by systemic factors. Continuity, frequency, and discrete seizures were unaffected by temperature and did not show variance within each temperature phase. There was a trend toward the emergence of interictal epileptiform discharges upon rewarming and mortality, but it was not statistically significant. Increased interictal epileptiform discharges with rewarming in post-CA therapeutic hypothermia patients may suggest poor prognosis, but a larger scale prospective study is needed.

Electroencephalogram characteristics in cooled and re-warmed periods in post-cardiac arrest therapeutic hypothermia patients (P2.232)

Electroencephalogram characteristics in cooled and re-warmed periods in post-cardiac arrest therapeutic hypothermia patients (P2.232)

National trends in the use of postcardiac arrest therapeutic hypothermia and hospital factors influencing its use.

Therapeutic hypothermia (TH) in cardiac arrest continues to be underused in the United States. A better understanding of its utilization could inform future efforts and policies to improve utilization. This study investigates trends in TH use for in and out-of-hospital cardiac arrest, and hospital factors associated with its use. We performed a cross-sectional analysis using the Nationwide Inpatient Sample (NIS), 2007-2010, of US adult hospitalizations with cardiac arrest. Annual rates of TH use and proportions of hospitals using TH were calculated using NIS weighting. Potential hospital factors associated with increased likelihood of TH utilization were assessed using logistic regression. Across 2007-2010, 1.35% of cardiac arrest patients received TH; increasing from 0.34% (2007) to 2.49% (2010). The proportion of hospitals using TH was 13.63%, increasing from 4.63% (2007) to 22.16% (2010). Significant hospital factors associated with TH utilization were: large hospitals, urban location, Northeast or West regions, teaching hospitals, non-safety net hospitals, increasing year, and hospitals with higher annual cardiac arrest volume. Utilization of TH in cardiac arrest remains low, but increased sevenfold from 2007 to 2010. The significant variability in implementation of TH, argues for nationwide best practices or regionalization of postcardiac arrest care hospitals.

Magnesium depletion in patients treated with therapeutic hypothermia after cardiac arrest.

Magnesium (Mg(2+)) depletion can have detrimental effects in postcardiac arrest patients through multiple potential mechanisms. Therapeutic hypothermia (TH) produces a Mg(2+) diuresis, but the effects of postcardiac arrest TH on serum Mg(2+) levels in patients with postcardiac arrest syndrome (PCAS) are yet to be systematically quantified. We conducted a retrospective chart review of 119 consecutive comatose PCAS patients treated with TH between 2005 and 2010 and compared them to 33 matched historic controls (HCs) seen at the same institution between 2002 and 2005 who were not treated with TH. We abstracted data from the first 96 hours postarrest, including date, time, and value of serum Mg(2+) levels and date, time, and amount of Mg(2+) repletion, along with outcomes at discharge. The median Mg(2+) level of TH patients was 2.0 mg/dL [interquartile range (IQR), 1.9-2.2 mg/dL] (0.82 mmol/L [IQR, 0.78-0.90 mmol/L]) versus 2.2 mg/dL [IQR, 1.9-2.4 mg/dL] (0.90 mmol/L [IQR, 0.82-0.99 mmol/L]) (p=0.2) in HCs. In addition, 42.9% (520/1214) of Mg(2+) levels in TH patients versus 31.9% (43/135) (p=0.014) in HC patients were below 2.0 mg/dL [0.82 mmol/L]. The average number of times the Mg(2+) level was checked in TH patients was 10.2 (range 1-18) versus 4.1 (range 1-10) in HCs. The TH patients were more likely to receive supplemental Mg(2+) than HCs (81.5% [97/119] vs. 27.3% [9/33] [p<0.01]). The mean supplemental Mg(2+) dose was 1.9 g for TH patients versus 0.5 g for HC patients. Mortality in patients treated with TH was 53.1% (60/113) versus 78.6% (22/28) (p=0.014) in HCs. Low serum Mg(2+) levels with subsequent Mg(2+) supplementation were more common in comatose patients with PCAS treated with TH compared to normothermic HC patients. The effect of untreated hypomagnesemia on postcardiac arrest outcomes remains to be determined.

Urine Output Changes During Postcardiac Arrest Therapeutic Hypothermia

While commonly described, no studies have characterized cold-induced diuresis or rewarm anti-diuresis occurring during the delivery of therapeutic hypothermia (TH). We sought to determine urine output changes during the provision of postcardiac arrest TH. We analyzed clinical data on patients receiving postcardiac arrest TH at an urban tertiary care center. TH measures included cooling by cold intravenous fluid, external ice packs, and a commercial external temperature management system. TH treatment was divided into phases: (1) induction, (2) maintenance, (3) rewarm, and (4) post-rewarm. The primary outcome measure was the mean urine output rate (mL/hour). We compared urine output rates between TH phases using a Generalized Estimating Equations model, defining urine output rate (mL/hour) as the dependent variable and TH phase (induction, maintenance, rewarm, and post-rewarm) as the primary exposure variable. We adjusted for age, sex, initial ECG rhythm, location of arrest, shock, acute kidney injury, rate of intravenous fluid input, and body mass index. Complete urine output data were available on 33 patients. Mean urine output rates during induction, maintenance, rewarm, and post-rewarm phases were 157 mL/hour (95% CI: 104-210), 103 mL/hour (95% CI: 82-125), 70 mL/hour (95% CI: 51-88), and 91 mL/hour (95% CI: 65-117), respectively. Compared with the post-rewarm phase, adjusted urine output was higher during the TH induction phase (output rate difference +51 mL/hour; 95% CI: 3-99). Adjusted urine output during the maintenance and rewarm phases did not differ from the post-rewarm phase. In this preliminary study, we observed modest increases in urine output during TH induction. We did not observe urine output changes during TH maintenance or rewarming.

Time to Rethink Sepsis as a Contraindication to Post Cardiac Arrest Therapeutic Hypothermia? A Retrospective Analysis of Outcomes of PCATH With and Without Ensuing Sepsis

Time to Rethink Sepsis as a Contraindication to Post Cardiac Arrest Therapeutic Hypothermia? A Retrospective Analysis of Outcomes of PCATH With and Without Ensuing Sepsis

An observational study of patient selection criteria for post-cardiac arrest therapeutic hypothermia

BackgroundTo date, there is no comprehensive assessment of how therapeutic hypothermia and post-arrest care are being implemented clinically. At this stage in the translation of post-arrest science to clinical practice, this analysis is overdue. This study examines the first step of post-arrest care – the selection of patients for TH and post-arrest care. MethodsWe conducted a systematic review to search for all publicly available TH and post-arrest protocols. Observational data was reported and no statistical inferences were made. ResultsNotable variation was observed in the following selection criteria: total ischemic time and hemodynamic requirements. Additionally, only some of the criteria were evidence based. ConclusionThis study demonstrates the wide range and variety of patient selection criteria that are being used for implementation of post-cardiac arrest care. The consequences of this selection criteria variability are currently unmeasured and likely underestimated. Variability is likely to breed inefficiency. Some patients who could benefit do not get treated. Other patients get cooled, yet will never regain consciousness. This variability may be important when considering inter-hospital variation in post-arrest care and outcomes.

Timing of EEG in Correlation to Prognosis in Postcardiac Arrest Therapeutic Hypothermia Patients (S28.007)

Timing of EEG in Correlation to Prognosis in Postcardiac Arrest Therapeutic Hypothermia Patients (S28.007)

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Introduction: Therapeutic hypothermia (TH) is an important treatment for survivors of cardiac arrest. While anecdotally described, no studies have characterized urine output increases during TH induction (“cold diuresis”), nor urine output decreases during TH re-warming (“re-warming anti-diuresis”). An understanding of urine output changes during TH is essential since these patients may exhibit hypovolemia, shock, pulmonary edema or electrolyte abnormalities. Hypothesis: Urine output increases during TH induction and decreases during TH re-warming. Methods: We studied consecutive patients receiving post-cardiac arrest TH at an urban tertiary care center. Using cold intravenous saline, external cooling pads (Arctic Sun) and ice packs, TH was provided to comatose adult survivors of out-of-hospital or in-hospital cardiac arrest as soon as possible after restoration of pulses. We excluded patients <18 years old, with end stage renal disease, who received hemodialysis, or those who died before completing?12 hours of TH. For each TH treatment phase (induction, maintenance, re-warm, and post-TH), we determined fluid input and urine output rates (mL/hr). Using Generalized Estimating Equations and defining post-TH urine output as the baseline, we examined the differences in urine output rates between TH phases, adjusting for fluid input rate, age, sex, location of cardiac arrest, initial arrest ECG rhythm, and vasospressor use. Results: Among 33 patients with complete fluid input and urine output data, mean treatment phase durations were: 1) induction 4.9 hrs (95% CI 4.5-5.4), 2) maintenance 23.1 hrs (22.5-23.6), 3) re-warm 11.1 hrs (10.5-11.7), and 4) post-rewarm 12 hrs (12-12). Mean urine output rates were: 1) induction 162 mL/hr (95% CI: 106-218), 2) maintenance 100 mL/hr (79-121), 3) re-warm 66 mL/hr (50-83), and post-TH 97 mL/hr (70-123). Urine output rate was higher for TH induction than post-TH (p=0.004). There were no significant differences in urine output rates between TH maintenance and post-TH (p=0.88), or TH re-warm and post-TH (p=0.19). Conclusions: Compared with baseline, urine output rate increases during TH induction. Urine output rates do not significantly change during TH maintenance or re-warming.

Abstract 75: Time to Awakening Is Often Delayed After Therapeutic Hypothermia for Post--Cardiac Arrest Patients

Introduction Withdrawal of care in patients after cardiac arrest has traditionally been based on the neurological exam at 72 hours after hospital arrival. For patients receiving post-cardiac arrest therapeutic hypothermia (TH), however, there is limited data to guide prognostication. We sought to describe the time to awakening for patients treated with TH and the relationships between time to awakening and outcome. Methods We performed a retrospective chart review of adult (age &gt; 18) cardiac arrest patients from January 2006 to January 2012 who were subsequently treated with TH at a large, academic community hospital. We abstracted demographic data, neurological assessments recorded by ICU nurses, including Glasgow Coma Scale (GCS), and survival data, including cerebral performance category (CPC) at discharge. We abstracted time intervals including intervals from arrival to target temperature (33.5°), interval to rewarming (35°C), and interval from arrival and rewarming to awakening. We defined awakening as GCS greater than 8, or GCS motor &gt;4 for intubated patients. Our primary outcome measure was good neurological outcome at discharge (CPC of 1 or 2). Descriptive statistics are reported. Results During the study period, 96 patients received TH (average age 60.3 years, 64.2% male). Overall, 39 (40.6%) patients survived to discharge, six were excluded (five did not awaken, one missing time data). Time (median, IQR) from ED arrival to rewarming was 41.0 (39,43) hours, ED arrival to awakening was 52.8 (43, 89) hours, and awakening to rewarming was 12.0 (2, 42) hours. The relationship between awakening and outcome is shown in table 1. Conclusion Although most patients with a good outcome awoke within 72 hours of hospital arrival or shortly after rewarming, a number of patients had awakening delayed more than 72 hours post arrival and rewarming. Our results support the need for longer periods of observation to determine outcomes for patients who receive post arrest TH.

Abstract 221: The Use of Invasive Hemodynamic Monitoring in Evaluating Resuscitative End Points in Post--Cardiac Arrest Therapeutic Hypothermia (COMICA Study Group)

Introduction: Patients who suffer from post-cardiac arrest syndrome (PCAS) often exhibit an inflammatory response similar to a sepsis syndrome. Invasive hemodynamic monitoring of resuscitative endpoints has been proven to impart better mortality outcomes in sepsis and has been recommended for goal-directed management of PCAS patients. Hypothesis: Centers engaged in aggressive post-cardiac arrest care will utilize invasive hemodynamic monitoring to ascertain adequacy of resuscitative endpoints including central venous pressure (CVP) and central venous oxygen saturation (ScvO 2 ). Methods: This study is a collaboration of 4 centers with aggressive PCAS and therapeutic hypothermia protocols. It is a secondary analysis from prospectively collected data of out-of-hospital cardiac arrest patients who underwent TH. The primary objective was to determine the use of invasive hemodynamic monitoring in the care of PCAS patients undergoing TH. The secondary objective was to determine if either CVP or ScvO 2 were associated with neurologic outcome measured as cerebral performance category (CPC), dichotomized into “good” (1 or 2) or “poor” (3, 4 or 5). Study variables were abstracted at baseline, 12, 24, 36 and 48 hrs. Results: A total of 111 patients were enrolled. Patients were 61 ± 16.8 yrs, 59.5% male, and had an initial rhythm of VF/VT in 50.5% of cases. At baseline, 11% (12/111) of patients had a CVP recorded and 3.6% (4/111) has ScvO 2 measured. During the middle 24 hrs, an average of 65% (72) of patients had CVP recordings and 21.6% (24) of patients had ScvO 2 recorded. ScvO 2 values were not different between patients with good versus poor neurologic outcome. Lower CVP measurement was associated with better neurologic outcome. Conclusion: ScvO 2 was infrequently utilized in this cohort of PCAS patients undergoing TH. CVP was utilized at higher rates, and lower CVP recordings were correlated with better neurologic outcome.

375 Mortality Outcomes From Post-Cardiac Arrest Therapeutic Hypothermia in a Community-Based, Multiple Hospital System

375 Mortality Outcomes From Post-Cardiac Arrest Therapeutic Hypothermia in a Community-Based, Multiple Hospital System

The Implementation of Therapeutic Hypothermia in the Emergency Department: A Multi-Institution Case Review

The use of therapeutic hypothermia (TH) is a burgeoning treatment modality for post-cardiac arrest patients. We performed a retrospective chart review of patients who underwent post-cardiac arrest TH at eight different institutions across the United States. Our objectives were to assess how TH is currently being implemented in emergency departments and to examine the feasibility of conducting TH research using multi-institution prospective data. A total of 94 cases were identified in a 3-year period and submitted for review by participating institutions of the Peri-Resuscitation Consortium. Of those, seven charts were excluded for missing data. Two independent reviewers performed the data abstraction. Results were subsequently compared, and discrepancies were resolved by a third reviewer. We assessed patient demographics, initial presenting rhythm, time until TH initiation, duration of TH, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharged. The majority of cases had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%). The inciting cardiac rhythm was unknown in 10.3% of cases. Time to initiation of TH ranged from 0 to 783 minutes with a mean time of 99 minutes (SD=132). Length of TH ranged from 25 to 2,171 minutes with a mean time of 1,191 minutes (SD=536). The average minimum temperature achieved was 32.5°C, with a range from 27.6°C to 36.7°C (SD=1.5°C). Of the 87 charts reviewed, 29 (33.3%) of the patients survived to hospital discharge. The implementation of TH across the country is extremely varied with no universally accepted treatment. While our study is limited by sample size, it illustrates some compelling trends. A large, prospective, multicenter trial or registry is necessary to elucidate further the optimal parameters for TH and its benefit in various population subsets.

Cerebellar Purkinje cell neurodegeneration after cardiac arrest: Effect of therapeutic hypothermia

AimsThe cerebellum is among the brain regions most vulnerable to damage caused by cardiac arrest, and cerebellar Purkinje cell loss may contribute to neurologic dysfunction, including post-hypoxic myoclonus. However, it remains unknown whether cerebellar Purkinje cells are protected by post-cardiac arrest therapeutic hypothermia (TH). Therefore, we examined the effect of post-cardiac arrest TH onset and duration on cerebellar Purkinje cell loss. MethodsSamples from a previously published study of post-cardiac arrest TH were utilized for the present analysis. Adult male rats subjected to asphyxial cardiac arrest and cardiopulmonary resuscitation were block randomized to normothermia (37.0°C) or TH (33.0°C) initiated 0, 1, 4, or 8h after return of spontaneous circulation (ROSC) and maintained for 24 or 48h. Cerebella from rats surviving 7 days after ROSC were processed for histology and immunohistochemistry. Purkinje cell density was quantified in Nissl-stained sections of the primary fissure of the cerebellar vermis. ResultsWith post-cardiac arrest normothermia, Purkinje cell density in the primary fissure was severely reduced compared to sham-injured controls (3.8±1.8cellsmm−1 vs. 35.9±2.4cellsmm−1, p<0.001). TH moderately improved Purkinje cell survival in all groups combined (14.0±5.6cellsmm−1, p<0.001 compared to normothermia). There was no statistical difference in Purkinje cell protection based on TH onset time or duration. ConclusionThese results indicate that post-cardiac arrest TH protects selectively vulnerable cerebellar Purkinje cells within a broad therapeutic window. The potential clinical implications for improving Purkinje cell survival require further investigation.

Post-Cardiac Arrest Therapeutic Hypothermia in New Jersey Hospitals: Analysis of Adoption and Implementation

While national guidelines recommend the use of therapeutic hypothermia (TH) for the treatment of out-of-hospital cardiac arrest (OHCA), adoption of the technique has been slow. In addition, little is known about how TH is applied in practice. This study sought to characterize the adoption and implementation of TH by acute care hospitals in the state of New Jersey. A survey of all 73 acute care hospitals in New Jersey was conducted to solicit information about TH adoption, application, and methods. Additional information was gained through a review of 18 written TH protocols (covering 21 hospitals). After growing slowly from 2004 to 2008, TH use among New Jersey hospitals accelerated between 2009 and 2011. By 2011, 68.4% of New Jersey hospitals had a TH program in place, with an additional 13.6% indicating plans to begin one. Most hospitals indicated low volumes of OHCA patients (e.g., ≤10 per month). There was no relationship between OHCA volume and development of a TH program. The per hospital volume of OHCA patients receiving TH is even lower given the extensive patient exclusion criteria used by many facilities. TH hospitals vary widely in their TH exclusion criteria and cooling equipment and methods. The vast majority of New Jersey hospitals are now organized to implement national TH guidelines for initial survivors of OHCA. However, limited volumes of OHCA cases per hospital and lack of uniformity on how the guidelines are implemented raise new questions about the effectiveness of current practice in postarrest care. More detailed analysis of TH volumes versus outcomes and comparative studies of TH techniques are required to optimize postarrest care.

Timing of neuroprognostication in postcardiac arrest therapeutic hypothermia*

Early assessment of neurologic recovery is often challenging in survivors of cardiac arrest. Further, little is known about when to assess neurologic status in comatose, postarrest patients receiving therapeutic hypothermia. We sought to evaluate timing of prognostication in cardiac arrest survivors who received therapeutic hypothermia. A retrospective chart review of consecutive postarrest patients receiving therapeutic hypothermia (protocol: 24-hr maintenance at target temperature followed by rewarming over 8 hrs). Data were abstracted from the medical chart, including documentation during the first 96 hrs post arrest of "poor" prognosis, diagnostic tests for neuroprognostication, consultations used for determination of prognosis, and outcome at discharge. Two academic urban emergency departments. A total of 55 consecutive patients who underwent therapeutic hypothermia were reviewed between September 2005 and April 2009. None. Of our cohort of comatose postarrest patients, 59% (29 of 49) were male, and the mean age was 56 ± 16 yrs. Chart documentation of "poor" or "grave" prognosis occurred "early": during induction, maintenance of cooling, rewarming, or within 15 hrs after normothermia in 57% (28 of 49) of cases. Of patients with early documentation of poor prognosis, 25% (seven of 28) had care withdrawn within 72 hrs post arrest, and 21% (six of 28) survived to discharge with favorable neurologic recovery. In the first 96 hrs post arrest: 88% (43 of 49) of patients received a head computed tomography, 90% (44 of 49) received electroencephalography, 2% (one of 49) received somatosensory evoked potential testing, and 71% (35 of 49) received neurology consultation. Documentation of "poor prognosis" occurred during therapeutic hypothermia in more than half of patients in our cohort. Premature documentation of poor prognosis may contribute to early decisions to withdraw care. Future guidelines should address when to best prognosticate in postarrest patients receiving therapeutic hypothermia.

Post–Cardiac Arrest Therapeutic Hypothermia: Overcoming the Barrier of Workplace Culture and Other Implementation Lessons

Therapeutic hypothermia (TH) is associated with improved neurologically intact survival after out-of-hospital cardiopulmonary arrest. Because of its complex multidisciplinary nature, many hospitals in the United States have resisted implementing TH. A post-cardiac arrest (post-arrest) TH program was implemented at a major urban academic medical center. IMPLEMENTING THE THERAPEUTIC HYPOTHERMIA PROGRAM: After initial efforts at TH at the University of Alabama at Birmingham Hospital nearly failed, the leaders restructured the TH program. Key elements included frequent multidisciplinary meetings involving all stakeholders, development of TH protocols and techniques consistent with customary institutional practices, introduction of cooling technology, and implementation of a TH physician rapid response system. During its first 21 months, the program initiated TH on 93 post-arrest patients. Of the 83 patients who achieved goal hypothermia temperature, 30 (36%; 95% confidence interval [CI]: 26%-47%) survived to hospital discharge. Care teams successfully managed expected complications. Of two patients with TH-associated coagulopathy, one required TH termination. The program illustrates key lessons for successful TH program implementation, such as the difficulty of organizing and coordinating complex interventions in complex institutions, the importance of overcoming workplace culture, the value of technology, the need for mid-course corrections, and the advantages of a physician-based rapid response system. Many of these lessons are applicable to any quality improvement intervention.

Development of a data dictionary for the Strategies for Post Arrest Resuscitation Care (SPARC) network for post cardiac arrest research

Background The widely accepted Utstein style has standardized data collection and analysis in resuscitation and post resuscitation research. However, collection of many of these variables poses significant practical challenges. In addition, several important variables in post resuscitation research are missing. Objective Our aim was to develop a comprehensive data dictionary and web-based data collection tool as part of the Strategies for Post Arrest Resuscitation Care (SPARC) Network project, which implemented a knowledge translation program for post cardiac arrest therapeutic hypothermia in 37 Ontario hospitals. Methods A list of data variables was generated based on the current Utstein style, previous studies and expert opinion within our group of investigators. We developed a data dictionary by creating clear definitions and establishing abstraction instructions for each variable. The data dictionary was integrated into a web-based collection form allowing for interactive data entry. Two blinded investigators piloted the data collection tool, by performing a retrospective chart review. Results A total of 454 variables were included of which 400 were Utstein, 2 were adapted from existing studies and 52 were added to address missing elements. Kappa statistics for two outcome variables, survival to discharge and induction of therapeutic hypothermia were 0.86 and 0.64, respectively. Conclusion This is the first attempt in the literature to develop a data dictionary as part of a standardized, pragmatic data collection tool for post cardiac arrest research patients. In addition, our dataset defined important variables that were previously missing. This data collection tool can serve as a reference for future trials in post cardiac arrest care.