Temperature Management For Cardiac Arrest Research Articles

Feasibility, Cooling Efficacy and Precisionofa Novel System for Temperature Management in Cardiac Arrest, Neurogenic Fever and Covid-19

Feasibility, Cooling Efficacy and Precisionofa Novel System for Temperature Management in Cardiac Arrest, Neurogenic Fever and Covid-19

Variation in the Use of Targeted Temperature Management for Cardiac Arrest

Targeted temperature management (TTM) is recommended for patients who do not respond after return of spontaneous circulation after cardiac arrest. However, the degree to which patients with cardiac arrest have access to this therapy on a national level is not known. Understanding hospital- and patient-level factors associated with receipt of TTM could inform interventions to improve access to this treatment among appropriate patients. Therefore, we performed a retrospective analysis using National Inpatient Sample data from 2016 to 2019. We used International Classification of Diseases, Tenth Edition diagnosis and procedure codes to identify adult patients with in-hospital and out-of-hospital cardiac arrest and receipt of TTM. We evaluated patient and hospital factors associated with receiving TTM. We identified 478,419 patients with cardiac arrest. Of those, 4,088 (0.85%) received TTM. Hospital use of TTM was driven by large, nonprofit, urban, teaching hospitals, with less use at other hospital types. There was significant regional variation in TTM capabilities, with the proportion of hospitals providing TTM ranging from >21% in the Mid-Atlantic region to <11% in the East and West South Central and Mountain regions. At the patient level, age >74 years (odds ratio [OR] 0.54, p <0.001), female gender (OR 0.89, p >0.001), and Hispanic ethnicity (OR 0.74, p <0.001) were all associated with decreased odds of receiving TTM. Patients with Medicare (OR 0.75, p <0.001) and Medicaid (OR 0.89, p=0.027) were less likely than patients with private insurance to receive TTM. Part of these differences was driven by inequitable access to TTM-capable hospitals. In conclusion, TTM is rarely used after cardiac arrest. Hospital use of TTM is predominately limited to a subset of academic hospitals with substantial regional variation. Older age, female gender, Hispanic ethnicity, and Medicare or Medicaid insurance are all associated with a decreased likelihood of receiving TTM.

Targeted Temperature Management in Cardiac Arrest: An Updated Narrative Review.

The established benefits of cooling along with development of sophisticated methods to safely and precisely induce, maintain, monitor, and reverse hypothermia have led to the development of targeted temperature management (TTM). Early trials in human subjects showed that hypothermia conferred better neurological outcomes when compared to normothermia among survivors of cardiac arrest, leading to guidelines recommending targeted hypothermia in this patient population. Multiple studies have sought to explore and compare the benefit of hypothermia in various subgroups of patients, such as survivors of out-of-hospital cardiac arrest versus in-hospital cardiac arrest, and survivors of an initial shockable versus non-shockable rhythm. Larger and more recent trials have shown no statistically significant difference in neurological outcomes between patients with targeted hypothermia and targeted normothermia; further, aggressive cooling is associated with a higher incidence of multiple systemic complications. Based on this data, temporal trends have leaned towards using a lenient temperature target in more recent times. Current guidelines recommend selecting and maintaining a constant target temperature between 32 and 36°C for those patients in whom TTM is used (strong recommendation, moderate-quality evidence), as soon as possible after return of spontaneous circulation is achieved and airway, breathing (including mechanical ventilation), and circulation are stabilized. The comparative benefit of lower (32-34°C) versus higher (36°C) temperatures remains unknown, and further research may help elucidate this. Any survivor of cardiac arrest who is comatose (defined as unarousable unresponsiveness to external stimuli) should be considered as a candidate for TTM regardless of the initial presenting rhythm, and the decision to opt for targeted hypothermia versus targeted normothermia should be made on a case-by-case basis.

TIMECARD score: An easily operated prediction model of unfavorable neurological outcomes in out-of-hospital cardiac arrest patients with targeted temperature management

Targeted temperature management (TTM) is recommended for comatose out-of-hospital cardiac arrest (OHCA) survivors. Several prediction models have been proposed; however, most of these tools require data conversion and complex calculations. Early and easy predictive model of neurological prognosis in OHCA survivors with TTM warrant investigation. This multicenter retrospective cohort study enrolled 408 non-traumatic adult OHCA survivors with TTM from the TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry during January 2014 to June 2019. The primary outcome was unfavorable neurological outcome at discharge. The clinical variables associated with unfavorable neurological outcomes were identified and a risk prediction score-TIMECARD score was developed. The model was validated with data from National Taiwan University Hospital. There were 319 (78.2%) patients presented unfavorable neurological outcomes at hospital discharge. Eight independent variables, including malignancy, no bystander cardiopulmonary resuscitation (CPR), non-shockable rhythm, call-to-start CPR duration >5min, CPR duration >20min, sodium bicarbonate use during resuscitation, Glasgow Coma Scale motor score of 1at return of spontaneous circulation, and no emergent coronary angiography, revealed a significant correlation with unfavorable neurological prognosis in TTM-treated OHCA survivors. The TIMECARD score was established and demonstrated good discriminatory performance in the development cohort (area under the receiver operating characteristic curve [AUC]=0.855) and validation cohorts (AUC=0.918 and 0.877, respectively). In emergency settings, the TIMECARD score is a practical and simple-to-calculate tool for predicting neurological prognosis in OHCA survivors, and may help determine whether to initiate TTM in indicated patients.

Post-resuscitation diastolic blood pressure is a prognostic factor for outcomes of cardiac arrest patients: a multicenter retrospective registry-based analysis

BackgroundPost-resuscitation hemodynamic level is associated with outcomes. This study was conducted to investigate if post-resuscitation diastolic blood pressure (DBP) is a favorable prognostic factor.MethodsUsing TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry, we recruited adult patients who received targeted temperature management in nine medical centers between January 2014 and September 2019. After excluding patients with extracorporeal circulation support, 448 patients were analyzed. The first measured, single-point blood pressure after resuscitation was used for analysis. Study endpoints were survival to discharge and discharge with favorable neurologic outcomes (CPC 1–2). Multivariate analysis, area under the receiver operating characteristic curve (AUC), and generalized additive model (GAM) were used for analysis.ResultsAmong the 448 patients, 182 (40.7%) patients survived, and 89 (19.9%) patients had CPC 1–2. In the multivariate analysis, DBP > 70 mmHg was an independent factor for survival (adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI, 1.41–3.31]) and > 80 mmHg was an independent factor for CPC 1–2 (aOR 2.04, 95% CI [1.14–3.66]). GAM confirmed that DBP > 80 mmHg was associated with a higher likelihood of CPC 1–2. In the exploratory analysis, patients with DBP > 80 mmHg had a significantly higher prevalence of cardiogenic cardiac arrest (p = 0.015) and initial shockable rhythm (p = 0.045).ConclusionWe found that DBP after resuscitation can predict outcomes, as a higher DBP level correlated with cardiogenic cardiac arrest.

Target Temperature Management Versus Normal Temperature Management for Cardiac Arrest After Traumatic Brain Injury Patient: A Meta-Analysis and Systemic Review.

This study compares the treatment outcomes between target temperature management (TTM) and normal temperature management (NTM) for cardiac arrest after traumatic brain injury (TBI). Two reviewers searched PubMed/MEDLINE, China National Infrastructure database for studies reporting on the use of TTM and NTM. All publications from inception to October 2021 were considered. Randomized control trials (RCTs) with cardiac arrest after TBI diagnoses were made based on the 2019 American Stroke Association (ASA) guidelines,1 wherein the included cardiac arrest patients underwent TTM or NTM treatment were included in this study. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommended tool was used for assessing the risk of bias of the included RCTs. In all, 1920 publications were identified. However, after applying the inclusion and exclusion criteria, 6 RCTs, including 1617 patients who received TTMs (n = 826) and NTMs (n = 791), were considered eligible. The meta-analysis indicated that compared with NTM, TTM did not show a decrease in the mortality, however, for those mild patients in the early stage, TTM still can decrease the mortality and better the prognosis. Compared with NTM, TTM is an effective measure to treat mild and severe patients in the early stage and improve the prognosis.

A Study on the Outcome of Targeted Temperature Management Comparing Cardiac Arrest Patients Who Received Bystander Cardiopulmonary Resuscitation With Those Who Did Not, Using the Nationwide TIMECARD Multicenter Registry.

Background and PurposeTargeted temperature management (TTM) is associated with decreased mortality and improved neurological function after cardiac arrest. Additionally, studies have shown that bystander cardiopulmonary resuscitation (BCPR) doubled the survival of patients with out-of-hospital cardiac arrest (OHCA) compared to patients who received no BPCR (no-BCPR). However, the outcome benefits of BCPR on patients who received TTM are not fully understood. Therefore, this study aimed to investigate the outcome differences between BCPR and no-BCPR in patients who received TTM after cardiac arrest.MethodsThe Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) multicenter registry established a study cohort and a database for patients receiving TTM between January 2013 and September 2019. A total of 580 patients were enrolled and divided into 376 and 204 patients in the BCPR and no-BCPR groups, respectively.ResultsCompared to the no-BCPR group, the BCPR group had a better hospital discharge and survival rate (42.25 vs. 31.86%, P = 0.0305). The BCPR group also had a better neurological outcome at hospital discharge. It had a higher average GCS score (11.3 vs. 8.31, P < 0.0001) and a lower average Glasgow–Pittsburgh cerebral performance category (CPC) scale score (2.14 vs. 2.98, P < 0.0001). After undertaking a multiple logistic regression analysis, it was found that BCPR was a significant positive predictor for in-hospital survival (OR = 0.66, 95% CI: 0.45–0.97, P = 0.0363).ConclusionsThis study demonstrated that BCPR had a positive survival and neurological impact on the return of spontaneous circulation (ROSC) in patients receiving TTM after cardiac arrest.

Association of time-temperature curves with outcomes in temperature management for cardiac arrest

Background/PurposeCardiac arrest is a common cause of death and neurological injury; therapeutic cooling for neuroprotection is standard of care. Despite numerous and ongoing trials targeting a specified cooling temperature for...

Targeted Temperature Management After In-Hospital Cardiac Arrest: An Ancillary Analysis of Targeted Temperature Management for Cardiac Arrest With Nonshockable Rhythm Trial Data

Targeted temperature management (TTM) currently is the only treatment with demonstrated efficacy in attenuating the harmful effects on the brain of ischemia-reperfusion injury after cardiac arrest. However, whether TTM is beneficial in the subset of patients with in-hospital cardiac arrest (IHCA) remains unclear. Is TTM at 33 °C associated with better neurological outcomes after IHCA in a nonshockable rhythm compared with targeted normothermia (TN; 37 °C)? We performed a post hoc analysis of data from the published Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm randomized controlled trial in 584 patients. We included the 159 patients with IHCA; 73 were randomized to 33 °C treatment and 86 were randomized to 37 °C treatment. The primary outcome was survival with a good neurologic outcome (cerebral performance category [CPC] score of 1 or 2) on day 90. Mixed multivariate adjusted logistic regression analysis was performed to determine whether survival with CPC score of 1 or 2 on day 90 was associated with type of temperature management after adjustment on baseline characteristics not balanced by randomization. Compared with TN for 48 h, hypothermia at 33 °C for 24h was associated with a higher percentage of patients who were alive with good neurologic outcomes on day 90 (16.4%vs5.8%; P= .03). Day 90 mortality was not significantly different between the two groups (68.5%vs76.7%; P= .24). By mixed multivariate analysis adjusted by Cardiac Arrest Hospital Prognosis score and circulatory shock status, hypothermia was associated significantly with good day 90 neurologic outcomes (OR, 2.40 [95%CI, 1.17-13.03]; P= .03). Hypothermia at 33 °C was associated with better day 90 neurologic outcomes after IHCA in a nonshockable rhythm compared with TN. However, the limited sample size resulted in wide CIs. Further studies of patients after cardiac arrest resulting from any cause, including IHCA, are needed.

Abstract EP03: 30-day Readmission Rates After Targeted Temperature Management For Cardiac Arrest

Background: In its 2015 guidelines, the American Heart Association instituted a Class 1 recommendation for use of Targeted Temperature Management (TTM) in patients with cardiac arrest (CA) . Prior observational studies have suggested benefits using TTM in these patients, while many randomized control trials have failed to replicate these results. Regardless, there have been studies with contradictory conclusions addressing readmission rates in patients receiving TTM. Thus, we sought to ascertain this relationship further by identifying 30-day readmission rates in Out-of-Hospital Cardiac Arrest (OHCA) patients receiving TTM. Methods: We utilized the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD) for data collection and International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes to identify 353,380 cardiac arrest cases and clinical variables. The primary outcome includes all-cause readmission rates within 30 days from cardiac arrest index admission discharge. We then conducted a logistic regression analysis after accounting for variables to assess odds of 30-day readmission in these patients. Results: TTM following CA was associated with a decreased likelihood of readmission at 30 days(OR: 0.822, p = 0.006, 95% CI [0.716-0.945]). Comorbidities associated with an increased risk of readmission after controlling for the other variables include congestive heart failure(OR: 1.259, p = 0.027, 95% CI [1.207-1.313]) and renal failure (OR: 1.363, p = 0.031, 95% CI [1.304- 1.425]). Of these patients receiving TTM compared to those who did not receive TTM, there was a greater proportion of cardiogenic shock (23.7% vs. 12.3%, p &lt; 0.001), acute heart failure (20.1% vs. 17.3%, p &lt; 0.001), coronary artery disease (53.0% vs. 46.2%, p &lt; 0.001), ischemic cardiomyopathy (61.7% vs. 53.1%, p &lt; 0.001), ventricular tachycardia (9.6% vs. 8.6%, p = 0.045), and ventricular fibrillation (56.6% vs. 24.1%, p&lt;0.001). Conclusion: TTM following CA is associated with decreased odds of readmission at 30 days. Prior long-term comorbidities represented most of the covariates for readmissions in this patient population.

The Differences of CPR duration between Shockable and Nonshockable Rhythms in Predicting the Benefit of Target Temperature Management.

Among cardiac arrest (CA) survivors, whether the combination of duration of cardiopulmonary resuscitation (CPR) and shockable/nonshockable rhythms during resuscitation can help predict the benefit of targeted temperature management (TTM) remains un-investigated. This multicenter retrospective cohort study enrolled 479 nontraumatic adult CA survivors with TTM and CPR duration < 60 min during January 2014 to June 2019 from the Taiwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry. The differences of CPR duration between shockable and nonshockable rhythms in predicting outcomes in the studied population was evaluated. We observed that 205 patients (42.8%) survived to hospital discharge and 100 patients (20.9%) presented favorable neurological outcomes at discharge. The enrolled patients were further re-classified into four groups according to shockable/nonshockable rhythms and CPR duration. Patients with shockable rhythms and shorter CPR duration had better survival-to-discharge (adjusted odds ratio [OR] = 2.729, 95% confidence interval [CI] = 1.384-5.383, P = 0.004) and neurological recovery (adjusted OR = 9.029, 95%CI = 3.263-24.983, P < 0.001) than did those with nonshockable rhythms and longer CPR duration. The CPR duration for predicting outcomes differs between CA patients with shockable and nonshockable rhythms. The combination of shockable/nonshockable rhythms and CPR duration may help predict the prognosis in CA survivors undergoing TTM.

Abstract 8894: Post-Resuscitation Diastolic Blood Pressure is a Better Predictive Factor for Outcomes of Cardiac Arrest Patients

Introduction: Post-resuscitation hemodynamic level was associated with outcomes. Our study hypothesized that post-resuscitation diastolic blood pressure (DBP) was a better predictive factor for outcomes. Methods: Starting from TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry, we recruited 540 adult patients who received target temperature management (TTM) during January 2014 and September 2019. After excluding 37 patients with pre-arrest cerebral performance categories scale (CPC) 3-4 and 55 patients with extracorporeal membrane oxygenation support, 448 patients were analyzed. Patient’s characteristics, comorbidities, resuscitation factors, arrest etiologies, systolic blood pressure (SBP) and DBP after resuscitation were included for analysis. Primary outcomes were survival of discharge (SOD) and discharge with favorable neurologic outcomes (CPC 1-2). Univariate and multivariate analysis were performed to identify favorable predictors. Predictive values of SBP and DBP for both outcomes were compared by calculating area under receiver operating characteristic (AUC). Results: Among 448 patients, 182 (40.7%) patients had SOD and 89 (19.9%) patients had CPC 1-2. DBP was significantly higher in patients with SOD (p&lt;0.001) and CPC 1-2 (p=0.003). In multivariate analysis, DBP was also an independent factor for SOD (p=0.004) and CPC 1-2 (p =0.048). When comparing SBP and DBP, DBP was a better predictor for CPC 1-2 (SBP AUC: 0.58 vs DBP AUC: 0.64, p=0.003). In subgroup analysis, DBP &gt; 80 served as a favorable predictor for both SOD and CPC 1-2. When comparing patients with DBP &lt;80 and SBP &gt;80, patients with higher DBP values had significantly higher percentage of cardiac etiologies arrest and relative higher percentage of initial shockable rhythm. Conclusion: DBP is a better hemodynamic parameter than SBP for predicting outcomes. In multivariate model, DBP &gt; 80 was an independent predictor for better survival and favorable neurologic outcomes.

Factors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry

Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM.We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables.The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome.In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.

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.

Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm

Current guidelines from the International Liaison Committee on Resuscitation (ILCOR) recommends that all patients with coma after successful resuscitation from cardiac arrest undergo targeted temperature management with moderate therapeutic hypothermia. However, some studies showed that these interventions had inconclusive effects, especially in patients who are presenting in cardiac arrest with non-shockable rhythms. These patients historically have poorer neurological outcomes compared to patients who present in cardiac arrest with shockable rhythms. With an equal number of studies showing benefit, harm, and no effect, and an increasing number of patients presenting in cardiac arrest with nonshockable rhythms, this study aims to identify whether or not therapeutic hypothermia provides benefit to this patient population. The objective of this study was to assess if therapeutic hypothermia at 33°C versus targeted normothermia improved neurological outcomes at 90 days in coma patients, specifically in those who were successfully resuscitated from nonshockable rhythms.

The association between early use of targeted temperature management and neurological outcome after cardiac arrest: a national registry research

Abstract Introduction Targeted temperature management (TTM) was shown to have favorable outcome in patients with cardiac arrest. However, there were still limited publications about the impact of the time intervalsfromreturn of spontaneous circulation (ROSC) to the initiation of TTMin patients after cardiac arrest.The aim of this study is toinvestigate the association between the time intervalsfrom ROSC to the initiation of TTMand the favorable neurological outcomes. Methods The data used the Taiwan Network of Targeted Temperature Management for Cardiac arrest (TIMECARD) registry database. Patients with cardiac arrest received TTMwere collected from June 2018 to June 2019. Very early, early, late, very late, and delayed TTM groups were defined as the time from cardiac arrest to initiation of TTM 0 to 5 hours,5 to 8 hours, 8 to 11 hours, 11 to 14 hours, and &amp;gt;14 hours respectively. A totalof 559 patients were divided into5 groups: very early group (N=82), early (N=150), late (N=118), very late (N=71) and delayed group (N=138). Results The baseline character were not different among 5 groups. Favorable neurological outcomes (cerebral performance category 1 and 2) in the very early, early, late, very late and delayed groupswere 66.67%, 33.33%, 50%, 25%, and 14.29% respectively. The Cox analysis showed very late and delayed group had worse neurologic outcome (HR=1.829, 95% CI=1.04- 3.23, p=0.0371). There is also trend to have worse neurologic outcome in late group (HR=1.734, 95% CI=0.91- 3.30, p=0.0939). Conclusion This national registry study demonstrated that early initiation of TTM in patients with cardiac arrest was associated with improved favorable neurological outcomes compared with those with late initiation of TTM. Funding Acknowledgement Type of funding source: None

Targeted temperature management in cardiac arrest patients with a non-shockable rhythm: A national perspective

Retrospective studies have shown conflicting benefit of utilizing targeted temperature management (TTM) in cardiac arrest (CA) patients with a non-shockable rhythm and presently there is only one randomized trial in this realm. We sought to determine trends and outcomes of TTM utilization in these patients from a large nationally representative United States population database. Data were derived from National Inpatient Sample (NIS) from January 2006 to December 2013. All patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Patients with evidence of shockable rhythm (ventricular tachycardia, ventricular flutter and ventricular fibrillation) were excluded. Trends in TTM utilization and mortality were assessed over our study period. Various outcomes were measured in patients receiving TTM and no TTM in unmatched and propensity matched cohorts. Logistic regression analysis was done to determine predictors of mortality. A total of 1,185,479 CA patients were identified in whom cause of arrest was a non-shockable rhythm. Overall, there was a steady increase in TTM utilization over our study period. In propensity-matched groups, mortality was higher in patients in whom TTM was utilized compared to non-TTM group (72.9% vs 68.7%, P < .01). In adjusted analysis, TTM remains an independent predictor of increased mortality in our group. Mortality remained high with TTM utilization regardless of location of CA. TTM utilization was associated with increased mortality in CA patients with a non-shockable rhythm. These findings merit further confirmation in a large randomized trial before application into clinical practice.

Somatosensory Evoked Potentials and Neuroprognostication After Cardiac Arrest.

Improved understanding of post-cardiac arrest syndrome and clinical practices such as targeted temperature management have led to improved mortality in this cohort. Attention has now been placed on development of tools to aid in predicting functional outcome in comatose cardiac arrest survivors. Current practice uses a multimodal approach including physical examination, neuroimaging, and electrophysiologic data, with a primary utility in predicting poor functional outcome. These modalities remain confounded by self-fulfilling prophecy and the withdrawal of life-sustaining therapies. To date, a reliable measure to predict good functional outcome has not been established or validated, but the use of quantitative somatosensory evoked potential (SSEP) shows potential for this use. MEDLINE and EMBASE search using words "Cardiac Arrest" and "SSEP," "Somato sensory evoked potentials," "qSSEP," "quantitative SSEP," "targeted temperature management in cardiac arrest" was conducted. Relevant recent studies on targeted temperature management in cardiac arrest, plus studies on SSEP in cardiac arrest in the setting of hypothermia and without hypothermia, were included. In addition, animal studies evaluating the role of different components of SSEP in cardiac arrest were reviewed. SSEP is a specific indicator of poor outcomes in post-cardiac arrest patients but lacks sensitivity and has not clinically been established to foresee good outcomes. Novel methods of analyzing quantitative SSEP (qSSEP) signals have shown potential to predict good outcomes in animal and human studies. In addition, qSSEP has potential to track cerebral recovery and guide treatment strategy in post-cardiac arrest patients. Lying beyond the current clinical practice of dichotomized absent/present N20 peaks, qSSEP has the potential to emerge as one of the earliest predictors of good outcome in comatose post-cardiac arrest patients. Validation of qSSEP markers in prospective studies to predict good and poor outcomes in the cardiac arrest population in the setting of hypothermia could advance care in cardiac arrest. It has the prospect to guide allocation of health care resources and reduce self-fulfilling prophecy.

Serum Magnesium Levels and Neurological Outcomes in Patients Undergoing Targeted Temperature Management After Cardiac Arrest

IntroductionMagnesium plays a neuroprotective role at the physiologic level, but its neuroprotective role in patients undergoing targeted temperature management for cardiac arrest is not well established. We performed multiple logistic regression analysis to evaluate whether magnesium levels can predict neurological outcomes in patients undergoing targeted temperature management after cardiac arrest. MethodsWe retrospectively investigated data on 86 patients who had undergone targeted temperature management after cardiac arrest between December 2015 and November 2017. The primary outcome was to determine whether magnesium levels predict unfavorable neurological outcomes for patients with return of spontaneous circulation after targeted temperature management. Cerebral Performance Category 3, 4, or 5 indicated unfavorable neurological outcomes. We performed multiple logistic regression to evaluate the primary outcome, adjusting for the time to return of spontaneous circulation, motor score of the Glasgow Coma Scale, first-recorded cardiac rhythm, pH, and magnesium levels. ResultsOf the 86 patients, 58 had unfavorable neurological outcomes. The mean hospital stay was 19 days. Multivariable analysis indicated that magnesium levels were not associated with an unfavorable neurological outcome. In contrast, a time to return of spontaneous circulation greater than 30 minutes and Glasgow Coma Scale motor score of 1 were significantly associated with an unfavorable neurological outcome. DiscussionMagnesium levels were not associated with an unfavorable neurological outcome according to multivariable analysis. We found that a time to return of spontaneous circulation greater than 30 minutes and Glasgow Coma Scale motor score of 1 might predict an unfavorable neurological outcome.

Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm

BackgroundModerate therapeutic hypothermia is currently recommended to improve neurologic outcomes in adults with persistent coma after resuscitated out-of-hospital cardiac arrest. However, the effectiveness of moderate therapeutic hypothermia in patients with nonshockable rhythms (asystole or pulseless electrical activity) is debated.MethodsWe performed an open-label, randomized, controlled trial comparing moderate therapeutic hypothermia (33°C during the first 24 hours) with targeted normothermia (37°C) in patients with coma who had been admitted to the intensive care unit (ICU) after resuscitation from cardiac arrest with nonshockable rhythm. The primary outcome was survival with a favorable neurologic outcome, assessed on day 90 after randomization with the use of the Cerebral Performance Category (CPC) scale (which ranges from 1 to 5, with higher scores indicating greater disability). We defined a favorable neurologic outcome as a CPC score of 1 or 2. Outcome assessment was blinded. Mortality and safety were also assessed.ResultsFrom January 2014 through January 2018, a total of 584 patients from 25 ICUs underwent randomization, and 581 were included in the analysis (3 patients withdrew consent). On day 90, a total of 29 of 284 patients (10.2%) in the hypothermia group were alive with a CPC score of 1 or 2, as compared with 17 of 297 (5.7%) in the normothermia group (difference, 4.5 percentage points; 95% confidence interval [CI], 0.1 to 8.9; P=0.04). Mortality at 90 days did not differ significantly between the hypothermia group and the normothermia group (81.3% and 83.2%, respectively; difference, −1.9 percentage points; 95% CI, −8.0 to 4.3). The incidence of prespecified adverse events did not differ significantly between groups.ConclusionsAmong patients with coma who had been resuscitated from cardiac arrest with nonshockable rhythm, moderate therapeutic hypothermia at 33°C for 24 hours led to a higher percentage of patients who survived with a favorable neurologic outcome at day 90 than was observed with targeted normothermia. (Funded by the French Ministry of Health and others; HYPERION ClinicalTrials.gov number, NCT01994772.)