Initiation Of Targeted Temperature Management Research Articles

Targeted Temperature Management for Patients with Acute Ischemic Stroke: A Literature Review.

Despite significant advances in medical imaging, thrombolytic therapy, and mechanical thrombectomy, acute ischemic strokes (AIS) remain a major cause of mortality and morbidity globally. Targeted temperature management (TTM) has emerged as a potential therapeutic intervention, aiming to mitigate neuronal damage and improve outcomes. This literature review examines the efficacy and challenges of TTM in the context of an AIS. A comprehensive literature search was conducted using databases such as PubMed, Cochrane, Web of Science, and Google Scholar. Studies were selected based on relevance and quality. We identified key factors influencing the effectiveness of TTM such as its timing, depth and duration, and method of application. The review also highlighted challenges associated with TTM, including increased pneumonia rates. The target temperature range was typically between 32 and 36 °C, with the duration of cooling from 24 to 72 h. Early initiation of TTM was associated with better outcomes, with optimal results observed when TTM was started within the first 6 h post-stroke. Emerging evidence indicates that TTM shows considerable potential as an adjunctive treatment for AIS when implemented promptly and with precision, thereby potentially mitigating neuronal damage and enhancing overall patient outcomes. However, its application is complex and requires the careful consideration of various factors.

Prognostic Performance of Initial Clinical Examination in Predicting Good Neurological Outcome in Cardiac Arrest Patients Treated with Targeted Temperature Management.

Prognostication studies of cardiac arrest patients have mainly focused on poor neurological outcomes. However, an optimistic prognosis for good outcome could provide both justification to maintain and escalate treatment and evidence-based support to persuade family members or legal surrogates after cardiac arrest. The aim of the study was to evaluate the utility of clinical examinations performed after return of spontaneous circulation (ROSC) in predicting good neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This retrospective study included OHCA patients treated with TTM from 2009 to 2021. Initial clinical examination findings related to the Glasgow coma scale (GCS) motor score, pupillary light reflex, corneal reflex (CR) and breathing above the set ventilator rate were assessed immediately after ROSC and before the initiation of TTM. The primary outcome was good neurological outcome at 6 months after cardiac arrest. Of 350 patients included in the analysis, 119 (34%) experienced a good neurological outcome at 6 months after cardiac arrest. Among the parameters of the initial clinical examinations, specificity was the highest for the GCS motor score, and sensitivity was the highest for breathing above the set ventilator rate. A GCS motor score of >2 had a sensitivity of 42.0% (95% confidence interval [CI] = 33.0-51.4) and a specificity of 96.5% (95% CI = 93.3-98.5). Breathing above the set ventilator rate had a sensitivity of 84.0% (95% CI = 76.2-90.1) and a specificity of 69.7% (95% CI = 63.3-75.6). As the number of positive responses increased, the proportion of patients with good outcomes increased. Consequently, 87.0% of patients for whom all four examinations were positive experienced good outcomes. As a result, the initial clinical examinations predicted good neurological outcomes with a sensitivity of 42.0-84.0% and a specificity of 69.7-96.5%. When more examinations with positive results are achieved, a good neurological outcome can be expected.

1137: FACTORS ASSOCIATED WITH FAVORABLE OUTCOMES IN CARDIAC ARREST AND TARGETED TEMPERATURE MANAGEMENT

Introduction: While guidelines strongly recommend targeted temperature management (TTM), whether early initiation of TTM or time-to-target temperature (TTT) are associated with better outcomes remains elucidated. To clarify if different target temperatures and shorter TTT are associated with favorable neurologic outcomes and reduced mortality in patients with coma after cardiac arrest undergoing TTM Methods: This is a retrospective observational study at a tertiary care hospital in Honolulu, Hawaii. Those who had an out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) undergoing TTM from November 1, 2020 to August 31, 2021 were included. Patients were dichotomized by the median time to TTM initiation, time from initiation of TTM to achieve target temperature, and TTT (into early and delayed groups). Results: 86 patients (53 with OHCA and 33 with IHCA), mainly including Asian and Native Hawaiian and Pacific Islanders, were included. In multinominal logistic regression analysis, the difference between the initial temperature to target temperature (Δ-temperature) and shorter TTT were identified as a factor positively associated with survival in the IHCA group. Conclusions: There may be specific groups of patients who are likely to benefit from the prompt initiation of TTM, focusing on Δ-temperature as a variable of interest. Further studies are warranted to identify underlying mechanisms associated with the results and response to TTM in different races/ethnicities.

1039: ON THIN ICE? REEVALUATING THE CLINICAL NEED FOR ENDOVASCULAR COOLING CATHETERS IN POST-ROSC CARE

Introduction: Targeted temperature management (TTM) is a widely practiced standard of care in post-cardiac arrest patients. Methods can include standard external cooling devices (SECD) and endovascular cooling catheters (ECC). Recent literature suggests that hypothermia is nonsuperior to normothermic therapy in reducing mortality amongst post-cardiac arrest patients. In a post-hoc analysis, ECCs were superior in achieving and maintaining target temperatures compared with SECDs. We aimed to re-examine the clinical benefit of using ECCs compared to SECDs in TTM of pre-hospital cardiac arrest patients in a real life clinical setting in an attempt to standardize provider practice in our institution. Methods: 116 patients presenting to the ED across 2019 suffering a pre-hospital cardiac arrest were retrospectively identified. Charts were separated into three groups: ECCs, alternative cooling methods, or no cooling and examined for temperature maintained over a 48 hour period after TTM initiation or admission, length of ICU stay, complications rates, and 28-day mortality. Kruskal Wallis test was used to detect a significant difference in mean temperature. Secondary outcomes were compared using independent sample t-tests. Results: 103 charts were analyzed and 13 charts removed for incomplete data. There was a statistically significant difference in maintenance of target temperature > 24 hours between patients in the “ECC group” compared to the “no cooling” and “alternative cooling methods” groups (p=< 0.0001). We found no significant differences in length of hospital stay (p=0.730), and overall mortality (p=0.881) between the three groups (p=0.881). Mean indwelling catheter time was one day. Complications included arterial puncture (n=1) in the ECC group. Conclusions: This retrospective study supports current literature suggesting superior TTM by ECCs. However, ECCs pose no significant benefit in reducing the length of ICU stay or decreasing mortality compared to standard methods, consistent with prior prospective studies. With the lack of significant survival benefits and increased risk of complications, the usage of ECCs may be more harmful than beneficial. The clinical merits of ECCs must be questioned and noninvasive measures should be considered more readily.

The Effect of Resuscitation Residents on the Duration of Pre-induction of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest.

Background The Resuscitation Rotation is a novel second-year emergency medicine rotation focusing on the highest acuity patients, including out-of-hospital cardiac arrest (OHCA). The resuscitation resident (RR) functions as an extra physician during resuscitation and post return of spontaneous circulation (ROSC). The objective of this study is to examine if the presence of a RR decreases the pre-induction interval of targeted temperature management (TTM) for patients following OHCA. Methods A retrospective study was conducted at a tertiary care level 1 trauma center with an annual ED census of 127,323 visits in 2019. We retrospectively reviewed consecutive OHCA patients from September 1, 2014, to July 20, 2020, who underwent TTM. Patients were identified as cases with or without a RR. Clinical characteristics were summarized by the status of RR involvement and compared by using t-test and χ2 test for continuous and categorical variables, respectively. All tests with p < 0.05 were considered to indicate statistical significance. Results Our study population identified 198 adult OHCA patients that underwent TTM from 2014-2020. There were exclusions for missing TTM start time and for missing patient characteristics leaving 176 for final analysis, of which 55 (33.3%) had RR involvement. The mean time (hours) to TTM initiation (ie, the pre-induction phase) for patients involving the RR versus those without was not statistically significant (3.11 vs 3.34, p=0.39). Linear regression analysis indicates that the adjusted effect of RR involvement was not associated with the mean hours of pre-induction (p=0.47). Conclusion There is no statistically significant association of a RR on the duration of the pre-induction phase. Limitations include that both arms had prolonged pre-induction phases. This may represent a non-optimized TTM protocol. Future work will aim to use the RR to improve our pre-induction phase.

FACTORS ASSOCIATED WITH FAVORABLE OUTCOMES IN CARDIAC ARREST AND TARGET TEMPERATURE MANAGEMENT

SESSION TITLE: Late Breaking Posters in Critical CareSESSION TYPE: Original Investigation PostersPRESENTED ON: 10/18/2022 01:30 pm - 02:30 pmPURPOSE: While guidelines strongly recommend targeted temperature management (TTM), whether early initiation of TTM or time-to-target temperature (TTT) are associated with better outcomes remains elucidated.METHODS: This is a retrospective observational study at a tertiary care hospital in Honolulu, Hawaii. Those who had an out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) undergoing TTM from November 1, 2020 to August 31, 2021 were included. Patients were dichotomized by the median time to TTM initiation, time from initiation of TTM to achieve target temperature, and TTT (into early and delayed groups).RESULTS: 86 patients (53 with OHCA and 33 with IHCA), mainly including Asian and Native Hawaiian and Pacific Islanders, were included. In multinominal logistic regression analysis, both Δ-temperature and TTT were not identified as factors associated with favorable neurological outcomes in neither OHCA nor IHCA groups. In the IHCA group, however, Δ-temperature and TTT were identified as factors associated with mortality, with a higher chance of survival in higher Δ-temperature (p = 0.039) and higher mortality in longer TTT patients (p = 0.017).CONCLUSIONS: There may be specific groups of patients who are likely to benefit from the prompt initiation of TTM, focusing on Δ-temperature as a variable of interest. Further studies are warranted to identify underlying mechanisms associated with the results and response to TTM in different races/ethnicities.CLINICAL IMPLICATIONS: The present study showed that there might be specific groups of patients who are likely to benefit from the prompt introduction of TTM, focusing on patients with baseline hyperthermia such as sepsis. Also, the results suggest the need to investigate the difference in response to TTM based on race and ethnicity since existing large-scale studies mainly included Caucasian patients.DISCLOSURES:No relevant relationships by Hangyul Chung-EsakiNo relevant relationships by Nobuhiko KimuraNo relevant relationships by Yoshito Nishimura SESSION TITLE: Late Breaking Posters in Critical Care SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: While guidelines strongly recommend targeted temperature management (TTM), whether early initiation of TTM or time-to-target temperature (TTT) are associated with better outcomes remains elucidated. METHODS: This is a retrospective observational study at a tertiary care hospital in Honolulu, Hawaii. Those who had an out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) undergoing TTM from November 1, 2020 to August 31, 2021 were included. Patients were dichotomized by the median time to TTM initiation, time from initiation of TTM to achieve target temperature, and TTT (into early and delayed groups). RESULTS: 86 patients (53 with OHCA and 33 with IHCA), mainly including Asian and Native Hawaiian and Pacific Islanders, were included. In multinominal logistic regression analysis, both Δ-temperature and TTT were not identified as factors associated with favorable neurological outcomes in neither OHCA nor IHCA groups. In the IHCA group, however, Δ-temperature and TTT were identified as factors associated with mortality, with a higher chance of survival in higher Δ-temperature (p = 0.039) and higher mortality in longer TTT patients (p = 0.017). CONCLUSIONS: There may be specific groups of patients who are likely to benefit from the prompt initiation of TTM, focusing on Δ-temperature as a variable of interest. Further studies are warranted to identify underlying mechanisms associated with the results and response to TTM in different races/ethnicities. CLINICAL IMPLICATIONS: The present study showed that there might be specific groups of patients who are likely to benefit from the prompt introduction of TTM, focusing on patients with baseline hyperthermia such as sepsis. Also, the results suggest the need to investigate the difference in response to TTM based on race and ethnicity since existing large-scale studies mainly included Caucasian patients. DISCLOSURES: No relevant relationships by Hangyul Chung-Esaki No relevant relationships by Nobuhiko Kimura No relevant relationships by Yoshito Nishimura

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

Association between initial body temperature and neurologic outcomes of out-of-hospital cardiac arrest patients undergoing targeted temperature management

Objective Targeted temperature management (TTM) is the core post-resuscitation treatment to minimize neurologic deficit after out-of-hospital cardiac arrest (OHCA). Abnormal initial body temperature (BT) can be associated with neurologic damage during arrest. We aimed to investigate the association between initial BT and neurologic outcomes of OHCA patients who underwent TTM. Methods This study used a nationwide OHCA database from January 2013 to December 2018. Among OHCA patients older than 18 years and with cardiac etiology, those with TTM treatment were included. BT at the initiation of TTM was categorized into three groups: low (35.5°C), normal (35.6°C−37.4°C), and high (37.5°C). The primary outcome was good neurologic recovery (Cerebral Performance Category 1 or 2). The association between initial BT and outcome was assessed using multivariable logistic regression analysis. Results A total of 1226 patients were analyzed, 354 (28.9%), 767 (62.6%), and 105 (8.6%) in the low, normal, and high BT groups, respectively. The good neurologic recovery rate was 15.0%, 39.9%, and 34.3% in these respective groups. The aOR for good neurologic recovery was 0.36 (95% confidence interval [CI], 0.25 to 0.51) in the low and 0.72 (95% CI, 0.43 to 1.22) in the high BT group compared with the normal BT group. Conclusion Low BT at the initiation of TTM was associated with unfavorable neurologic recovery for OHCA patients who underwent TTM. Keywords: Out-of-Hospital Cardiac Arrest, Induced Hypothermia, Body Temperature

Outcomes of Targeted Temperature Management for In-Hospital and Out-Of-Hospital Cardiac Arrest: A Matched Case-Control Study Using the National Database of Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) Registry.

BackgroundThis study aimed to compare outcomes of targeted temperature management (TTM) for patients with in-hospital and out-of-hospital cardiac arrest using the national database of TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry.Material/MethodsA retrospective, matched, case-control study was conducted. Patients with in-hospital cardiac arrest (IHCA) treated with TTM after the return of spontaneous circulation (ROSC) were selected as the case group and controls were defined as the same number of patients with out-of-hospital cardiac arrest (OHCA), matched for sex, age, Charlson comorbidity index, and cerebral performance category. Neurological outcome and survival at hospital discharge were the primary outcome measures.ResultsData of 103 patients with IHCA and matched controls with OHCA were analyzed. Patients with IHCA were more likely to experience witnessed arrest and bystander cardiopulmonary resuscitation (CPR). The duration from collapse to the beginning of CPR, CPR time, and the duration from ROSC to initiation of TTM were shorter in the IHCA group but their initial arterial blood pressure after ROSC was lower. Overall, 88% of patients survived to completion of TTM and 43% survived to hospital discharge. Hospital survival (42.7% vs 42.7%, P=1.00) and favorable neurological outcome at discharge (19.4% vs 12.7%, P=0.25) did not differ between the 2 groups.ConclusionsThe findings from the national TIMECARD registry showed that clinical outcomes following TTM for patients with IHCA were not significantly different from OHCA when baseline factors were matched.

Assessing the impact of resuscitation residents on the treatment of cardiopulmonary resuscitation patients.

The management of cardiac arrest patients receiving cardiopulmonary resuscitation (CPR) is an essential aspect of emergency medicine (EM) training. At our institution, we have a 1-month Resuscitation Rotation designed to augment resident training in managing critical patients. The objective of this study is to compare 30-day mortality between cardiac arrest patients with resuscitation resident (RR) involvement versus patients without. Our secondary outcome is to determine if RR involvement altered rates of initiating targeted temperature management (TTM). This study was conducted at a single site tertiary care Level-1 trauma center with an Emergency Department (ED) census of nearly 130,000 visits per year. Data was collected from 01/01/2015 to 01/01/2018 using electronic medical records via query. Patients admitted with cardiac arrest were separated into two groups, one with RR involvement and one without. Initial rhythm of ventricular fibrillation/tachycardia (VFIB/VTACH), 30-day mortality, history of coronary artery disease (CAD), and initiation of TTM were compared. Statistical analysis was performed. Out of 885 patient encounters, 91 (10.28%) had RR participation. There was no statistical difference in 30-day mortality between patients with RR involvement compared to those without (71.42% vs 66.36%; P=0.3613). However, TTM was initiated more in the RR group (20.70% vs 8.86%; P=0.0025). Patients who received TTM also had a lower 30-day mortality compared to those without TTM (52.94% vs 70.87%; P=0.0020). Patients who were older and had no history of CAD were also noted to have a statistically significant higher 30-day mortality. All other variables were not statistically significant. Resuscitation resident involvement with the care of cardiac arrest patients had no impact in 30-day mortality. However, the involvement of RR was associated with a statistically significant increase in the initiation of TTM. One limitation is that RR participated in 10.28% of the cases analyzed herein, thus the two arms are unbalanced in size. Future work may investigate if the increase in TTM in the RR involved cases may portend improved rates of neurologically intact survival or more rapid achievement of goal temperatures.

Targeted Temperature Management for Treatment of Cardiac Arrest

Purpose of reviewCardiac arrest is a common condition associated with high mortality and a substantial risk of neurological injury among survivors. Targeted temperature management (TTM) is the only strategy shown to reduce the risk of neurologic disability cardiac arrest patients. In this article, we provide a comprehensive review of TTM with an emphasis on recent trials.Recent findingsAfter early studies demonstrating the benefit of TTM in out-of-hospital cardiac arrest due to a shockable rhythm, newer studies have extended the benefit of TTM to patients with a nonshockable rhythm and in-hospital cardiac arrest. A target temperature of 33 °C was not superior to 36 °C, suggesting that a lenient targeted temperature may be appropriate especially for patients unable to tolerate lower temperatures. Although early initiation of TTM appears to be beneficial, the benefit of prehospital cooling has not been shown and use of intravenous cold saline in the prehospital setting may be harmful.SummaryThere is substantial risk of neurological injury in cardiac arrest survivors who remain comatose. TTM is an effective treatment that can lower the risk of neurological disability in such patients and ideally delivered as part of a comprehensive, goal-directed post-resuscitation management by a multidisciplinary team in a tertiary medical center.

320 Post Cardiac Arrest Care: Does Usual Care Comply With Guidelines and Impact Outcomes?

Guideline-based post-arrest care includes efforts to determine and treat the cause of arrest while minimizing cardiac dysfunction and brain injury resulting from lack of perfusion. Diagnostic testing such as early head imaging, electrocardiogram and other imaging studies may help determine the etiology of arrest. Mitigating injury to brain and heart involves maintaining adequate blood pressure, targeted temperature management (TTM) and early diagnosis and treatment of seizures with electroencephalogram (EEG). Our institution created a set of evidence-based guidelines for the management of post-arrest patients which, in addition to the above, also recommends early consultation with the neurocritical care service and an early echocardiogram. We aim to examine compliance with the guidelines in a cohort of survivors of out-of-hospital cardiac arrest (OHCA) and related outcomes. Retrospective cohort study of patients with OHCA at two urban emergency departments (ED) within a health system between 7/2016 and 7/2018. Exclusion criteria included age < 18 years old and if CPR was terminated upon arrival. Data were extracted from an internal institutional quality improvement database maintained of all resuscitative measures. We abstracted demographic data, Utstein criteria (rhythm, bystander CPR) and time of arrest (day vs night). Quality measures included NCC consultation, cEEG, and computed tomography (CT) of the brain within 6 hours of admission. Descriptive statistics are provided as indicated. Chi-squared and two-sided t tests were used to determine differences in univariate analysis. An alpha < 0.05 was used for statistical significance. 124 patients presented with OHCA, of which 41 (33.0%) were comatose and survived to admission. Nearly 83% (34 /41patients) of these patients received guideline-recommended TTM:, 15 were targeted to low temperature (34 C) and 19 targeted to higher temperature (35 C). Seventeen patients of 41 (41.4%) received an early head CT in the ED, 17/41 (41.4%) patients were placed on cEEG and 23/41 (56.1%) patients received a NCC consult. Five of these comatose 43 patients (11.6 %) survived to discharge. The presence of a shockable rhythm was associated with a higher likelihood of receiving TTM (p= 0.005), and also higher rates of survival to discharge (p= 0.025). No significant differences were seen in the initiation of TTM when comparing demographics and Utstein criteria, and variation in temperature goal did not affect survival to discharge. Seventeen patients received an early head CT, 17 patients were placed on cEEG and 23 patients received a NCC consult. 5 patients (12 %) survived to discharge. Of these quality processes, only initiation of TTM was associated with survival to hospital discharge. No significant differences were seen in the initiation of TTM when comparing demographics and Utstein criteria, and variation in temperature goal did not affect survival to discharge. While four out of five survivors of OHCA received TTM, compliance with the other recommendations for the post arrest algorithm was variable. Presence of a shockable rhythm was most associated with TTM compliance and was the strongest predictor of survival to hospital discharge. Further studies are needed to investigate whether better outcomes will result from improving usual care to include compliance with the guidelines.

Risks According to the Timing and Frequency of Hypotension Episodes in Postanoxic Comatose Patients.

The aim of this study was to assess the risk of unfavorable outcomes according to the timing of hypotension episodes in cardiac arrest patients. This prospectively conducted multicenter observational study included 1373 out-of-hospital cardiac arrest patients treated with 33 °C targeted temperature management (TTM). Unfavorable neurological outcome and the incidence of complications were analyzed according to the timing of hypotension. Compared with hypotension before TTM initiation (adjusted hazard ratio (aHR) 1.51), hypotension within 6 h after TTM initiation was associated with an increased risk of unfavorable neurologic outcome (aHR 1.693), and after 24 h of TTM, was connected with decreased risk (aHR 1.277). The risk of unfavorable neurological outcome was gradually reduced over time after TTM initiation. Hypotension, persisting both before and during TTM, demonstrated a greater risk (aHR 2) than transient hypotension (aHR 1.265). Hypotension was correlated with various complications. Differences in lactate levels were persistent, regardless of the initial fluid therapy (p < 0.001). Hypotension showed a strong correlation with unfavorable neurological outcome, especially in the early phase after TTM initiation, and complications. It is essential to manage hypotension that occurs at the beginning of TTM initiation to recover cerebral function in cardiac arrest patients.

Targeted temperature management: beneficial or not?

Targeted temperature management (TTM), formerly known as therapeutic hypothermia, has been shown to improve survival and neurological recovery in patients following cardiac arrest. Following successes with its in-hospital implementation, many guidelines now advocate its use in the prehospital domain for all out-of-hospital cardiac arrests (OHCAs). It has been suggested that patients presenting with shockable rhythms who receive early initiation of TTM have better survival rates. TTM can be initiated in the prehospital setting with minimal equipment. This article discusses and explores the potential benefits and pitfalls of targeted temperature management when initiated in the prehospital environment. Particular focus is given to potential treatment strategies that can be used by paramedics to adequately manage OHCA. It is proposed that prehospital TTM is advantageous to all patients in cardiac arrest and can be efficacious in a variety of prehospital environments, with its implementation requiring only minimal equipment.

Cold fluids for induction of targeted temperature management: A sub-study of the TTH48 trial

BackgroundPre-intensive care unit (ICU) induction of targeted temperature management (TTM) with cold intravenous (i.v.) fluids does not appear to improve outcomes after in out-of-hospital cardiac arrest (OHCA). We hypothesized that this may be due to ineffective cooling and side effects. MethodsA post hoc analysis of a sub-group of patients (n = 352) in the TTH48 trial (NCT01689077) who received or did not receive pre-ICU cooling using cold i.v. fluids. Data collection included patient characteristics, cardiac arrest factors, cooling methods, side effects and continuous core temperature measurements. The primary endpoint was the time to target temperature (TTT, <34 °C), and the secondary endpoints included the incidence of circulatory side effects, abnormal electrolyte levels and hypoxia within the first 24 h of ICU care. A difference of 1 h in the TTT was determined as clinically significant a priori. ResultsOf 352 patients included in the present analysis, 110 received pre-ICU cold fluids. The median time to the return of spontaneous circulation (ROSC) and TTT in the pre-ICU cold fluids group was longer than that of the group that did not receive pre-ICU cold fluids (318 vs. 281 min, p < 0.01). In a linear regression model including the treatment centre, body mass index (BMI), chronic heart failure, diabetes mellitus and time to ROSC, the use of pre-ICU cold i.v. fluids was not associated with a shorter time to the target temperature (standardized beta coefficient: 0.06, 95% CI for B -49 and 16, p = 0.32). According to the receipt or not of pre-ICU cold i.v. fluids, there was no difference in the proportion of patients with hypoxia on ICU admission (1.8% vs. 3.3%, p = 0.43) or the proportion of patients with electrolyte abnormalities (hyponatremia: 1.8% vs. 2.9% p = 0.54; hypokalaemia: 1.8% vs. 4.5%, p = 0.20). Furthermore, there was no difference in hospital mortality between the groups. ConclusionsThe initiation of TTM with cold i.v. fluids before ICU arrival did not decrease the TTT. We detected no significant between-group difference in mortality or the incidence of side effects according to the administration or not of pre-ICU cold i.v fluids.

Improvement of consciousness before initiating targeted temperature management

IntroductionFollowing cardiac arrest, return of spontaneous circulation (ROSC) in patients may be followed by spontaneous neurological recovery, which may decrease the potential adverse effects of treatments in post-cardiac arrest care, including those of Targeted Temperature Management (TTM). We investigated the percentage of post-arrest patients who experienced spontaneous neurological recovery, and the characteristics and neurological outcomes of these patients. MethodsA total of 540 patients with ROSC were retrospectively enrolled in this single-center observational study. The patients’ motor responses were documented immediately and at 3 h following ROSC. Predictors of spontaneous neurological recovery were assessed by multiple logistic regression analysis. ResultsA total of 221 patients (41%) showed a change in their GCS (Glasgow Coma Score) M score (motor score) during the 3-h interval following ROSC, with improvement evident in 215 patients. Among 96 patients with GCS M6 at 3 h, 83 (86%) were discharged with a favorable neurological outcome. GCS M6 at 3 h post ROSC, was an independent predictor for a favorable neurological outcome, but GCS M6 at ROSC was not. There were four factors predicting the GCS M6 at 3 h; including in-hospital cardiac arrest (OR 3.057; 95% CI: 1.370–6.824, P = 0.006); bystander CPR (OR 13.311; 95% CI: 6.455–27.447, P < 0.0001); the CPR duration (OR, 0.941; 95% CI: 0.91–0.974; P < 0.0001), and the initial shockable rhythm (OR, 4.41; 95% CI: 2.44–7.95; P < 0.0001). ConclusionsA significant portion of patients had spontaneous neurological recovery to GCS M6 within 3 h post ROSC, and had a favorable neurological outcome. Close monitoring of GCS and later initiation of TTM should be considered in those patients with a substantial likelihood of neurological recovery.

Abstract 158: Association Between Initial Body Temperature and Neurologic Outcomes of Out-Of-Hospital Cardiac Arrest Undergoing Targeted Temperature Management

Objectives: Targeted temperature management (TTM) is the core post-resuscitation care to minimize neurologic deficit after out-of-hospital cardiac arrest (OHCA). Uncontrolled body temperature of patients may reflect the thermoregulation ability which can be associated with neurologic damage during arrest. The aim of this study was to investigate the association between initial body temperature (BT) and neurologic outcomes in OHCA patients who underwent TTM. Methods: We used nationwide OHCA database from January 2016 to December 2017. Adult OHCA patients with presumed cardiac etiology who underwent TTM after return-of-spontaneous circulation (ROSC) were included. The main exposure was a BT at initiation of TTM which was categorized into 3 groups: low (-35.5°c), middle(35.6°c-37.4°c), and high BT (37.5°c-). The primary outcome was good neurologic outcome (cerebral performance categories (CPC) 1 or 2). Adjusted ratios (AORs) and 95% confidence intervals (CIs) were estimated to evaluate association between initial BT of TTM and outcome in multivariable logistic regression model. Stratified subgroup analyses were according to the target temperature of TTM (hypothermia vs normothermia). Results: Of a total of 744 patients, 208 (28.0%) patients were low initial BT group and 471 (63.3%) patients were normal initial BT group and 65 (8.7%) patients were high initial BT group. Good neurological recovery rate was 13.9% in low initial BT group, 41.8% in middle initial BT group and 36.9% in high initial BT group. The adjusted odds ratios for good neurologic recovery were 0.281 (95% confidence interval [CI] 0.17-0.47) in low BT group and 0.65 (95% CI 0.34-1.27) in high BT group compared with normal initial BT group. Similar results were also found regardless of target temperature of TTM. Conclusion: Low initial BT of TTM was associated with unfavorable neurologic recovery for OHCA patients who underwent TTM after ROSC.

Abstract 107: Cardiac Arrest Outcomes After Target Temperature Management With an Esophageal Cooling Device

Introduction: Optimal patient care after cardiac arrest includes targeted temperature management (TTM). Methods typically utilized for patient temperature control, including ice-packs, servo-controlled surface pads, and intravascular catheters. A new device placed in the esophagus that cools from the patient’s core may offer advantages over other methods. It avoids risks from intravascular catheters, reduces shivering from surface contact, and allows core temperature control to be rapidly performed, after placement, by nursing staff. Hypothesis: Using a nurse driven protocol we sought to quantify patient outcomes, after TTM, using an esophageal device, in our mixed-population intensive care unit. Methods: We reviewed the charts of all patients treated with esophageal TTM as part of our standard post-arrest bundle at our advanced community medical center. We recorded patient age, gender, target temperature, TTM initiation time, the time goal temperature was attained, and patient survival. Results: A total of 54 patients were treated with esophageal TTM over the study period, from August 2016 to November 2018. Of these 2 recovered and had treatment discontinued prior to reaching target, leaving 52 for analysis (19 female, 33 male, age 18-79, median age 62.5). Nurses placed all ETM devices, and target temperatures varied by clinician preference, from 32°C to 36°C. Survival to ICU discharge was 51.9% for the entire cohort, with male survival (61%) greater than female (37%), p=0.10; however, Cfor the entire cohort was 219 minutes (IQR 81-415). Survivors exhibited longer times to achieve goal temperature (median 180 minutes in non-survivors vs. 255 minutes in survivors). Conclusions: Esophageal TTM offers a nurse-driven approach to obtain rapid core temperature management, with good outcomes in our patient population. As seen elsewhere, surviving patients require longer times to reach target temperature.

Predicting the outcomes of targeted temperature management for children with seizures and/or impaired consciousness accompanied by fever without known etiology

BackgroundSeizures and/or impaired consciousness accompanied by fever without known etiology (SICF) is common in the pediatric emergency setting. No optimal strategy for the management of SICF in childhood currently exists. We previously demonstrated the effectiveness of targeted temperature management (TTM) against SICF with a high risk of morbidity; however, some patients with SICF develop neurological sequelae despite TTM, which necessitate additional neuroprotective treatment. The clinical characteristics of these severe cases have not been studied. Accordingly, the aim of this study was to identify the clinical characteristics of children with SICF who exhibit poor outcomes after TTM. MethodsThe medical records of children admitted to Kobe Children’s Hospital (Kobe, Japan) between October 2002 and September 2016 were retrospectively reviewed. Patients with SICF treated using TTM were included and divided into the satisfactory and poor outcome groups. Univariate and multivariate logistic regression analyses were used to compare clinical characteristics and laboratory findings between the two groups. ResultsOf the 73 included children, 10 exhibited poor outcomes. Univariate logistic regression analysis revealed that acute circulatory failure before TTM initiation, the use of four or more types of anticonvulsants, methylprednisolone pulse therapy, and an aspartate aminotransferase (AST) level ≥73 IU/L were associated with poor outcomes. Multivariate logistic regression analysis identified an elevated AST level as a significant independent predictor of a poor outcome. ConclusionsAn elevated AST level within 12 h of onset in children with SICF is an independent predictor of a poor outcome after TTM initiated within 24 h of onset.

Invasive Hemodynamics and Outcomes in Cardiac Arrest Survivors Undergoing Targeted Temperature Management

Most important prognostic factors in the postcardiac arrest patients who underwent targeted temperature management (TTM) derive from the periarrest period. Whether early invasive hemodynamics predict survival or neurologic outcomes remains unknown. We retrospectively reviewed all comatose survivors of cardiac arrest who underwent TTM at the Coronary Intensive Care Unit of a Quaternary Center between January 2015 and June 2017. Patients were required to have a set of invasive hemodynamics available at initiation of TTM to be included. Those with cooling initiated before admission and temperature of <36°C before obtaining hemodynamics were excluded. Univariate logistic and multivariate regression were conducted to test whether cardiac index (Fick-cardiac index ≥2.2 vs <2.2 L/min/m2), pulmonary capillary wedge pressure (PCWP ≥18 vs <18 mm Hg), systemic vascular resistance (SVR >1200 vs 800 to 1200 vs <800 dynes⋅s/cm5) or Forrester hemodynamic profiles were predictive of survival and favorable neurologic outcomes at hospital discharge. Total of 52 consecutive arrest survivors who underwent TTM were studied demonstrating a wide variability in invasive hemodynamic parameters. There was no association between cardiac index (p = 0.45 and p = 0.10), PCWP (p = 0.90 and p = 0.60), SVR (0.95 and p = 0.17) or Forrester hemodynamic profiles (p = 0.40 and p = 0.42) and survival or favorable neurologic outcome at discharge. In conclusion, comatose arrest survivors who underwent TTM presents with a wide spectrum of invasive hemodynamics highlighting the heterogeneity of the postcardiac arrest syndrome. Early invasive hemodynamics did not predict survival or favorable neurologic outcomes at hospital discharge.