Therapeutic Hypothermia In Patients Research Articles

Is there still a role for hypothermia in neurocritical care?

Therapeutic hypothermia (i.e. induced body core temperature ≈ 33-35°C) in neurological patients with cerebrovascular disease and traumatic brain injury is a controversially discussed issue in the literature. In this review, we have included the most recently published research covering the use of therapeutic hypothermia and targeted temperature management in neurologic diseases and translated the results into a clinical decision support for the professional healthcare community. Recent findings from large multicenter studies investigating therapeutic hypothermia in patients with various acute neurologic diseases have revealed that although short-term and long-term temperature modulation on different temperature levels is feasible with the latest device technology, the effect on outcome is controversial. There is overwhelming evidence that fever is an independent predictor of morbidity and mortality in patients with acute severe neurologic diseases. Although therapeutic hypothermia has been proven to be a potent neuroprotective measure acting on various levels in animal models, many questions such as optimal depth of target temperature, speed of rewarming, duration of cooling and management of side-effects accompanying therapeutic hypothermia are unresolved in human. Therefore, the application of therapeutic hypothermia outside of strictly supervised clinical trials must be carefully considered.

MILD HYPOTHERMIA IN CARDIOGENIC SHOCK COMPLICATING MYOCARDIAL INFARCTION: THE RANDOMIZED SHOCK-COOL PILOT TRIAL

Background —Experimental trials suggest improved outcome by mild therapeutic hypothermia for cardiogenic shock following acute myocardial infarction. The objective of this study was to inves-tigate hemodynamic effects of mild therapeutic hypothermia in patients with cardiogenic shock complicating acute myocardial infarction. Methods —Patients (n=40) with cardiogenic shock undergoing primary percutaneous coronary in-tervention without classical indication for mild therapeutic hypothermia underwent randomization in a 1:1 fashion to mild therapeutic hypothermia for 24 h or control. The primary endpoint was cardiac power index at 24 h; secondary endpoints included other hemodynamic parameters as well as serial measurements of arterial lactate. Results —No relevant differences were observed for the primary endpoint cardiac power index at 24 h (mild therapeutic hypothermia vs. control: 0.41 [interquartile range 0.31-0.52] vs. 0.36 [inter-quartile range 0.31-0.48] W/m 2 ; p=0.50, median difference -0.025 [95% confidence interval -0.12 to 0.06 W/m 2 ]). Similarly, all other hemodynamic measurements were not statistically different. Arterial lactate levels at 6, 8 and 10 hours were significantly higher in patients in the MTH group with a slower decline (p for interaction 0.03). There were no differences in 30-day mortality: (60 vs. 50%, hazard ratio 1.27 [95% confidence interval 0.55-2.94]; p=0.55). Conclusions —In this randomized trial mild therapeutic hypothermia failed to show a substantial beneficial effect in patients with cardiogenic shock after acute myocardial infarction on cardiac power index at 24 h. Clinical Trial Registration —URL: www.clinicaltrials.gov Unique Identifier: NCT01890317

THERAPEUTIC HYPOTHERMIA FOR IN-HOSPITAL CARDIAC ARREST: A META ANALYSIS

Background: Multiple randomized controlled trials have demonstrated the favorable impact of Therapeutic Hypothermia (TH) in out of hospital cardiac arrest. The benefit of TH for patients with In-Hospital Cardiac Arrest (IHCA) remains unclear. There have been no RCTs and results of observational

No benefits of hypothermia in patients treated with hemicraniectomy for large ischemic stroke.

Background Space-occupying middle cerebral artery brain infarcts are associated with the development of brain edema, which may lead to cerebral herniation and death despite early hemicraniectomy. Aims To evaluate the benefit of therapeutic hypothermia in patients with space-occupying cerebral infarction treated with hemicraniectomy within 48 h of stroke onset. Methods Patients aged 18-60 years with space-occupying cerebral infarction treated with hemicraniectomy within 48 h and hypothermia (33-34°C) were selected from a single university hospital between 2001 and 2010 (n = 53). Patients treated with hemicraniectomy alone served as comparison group (n = 58), originating from three randomized controlled trials evaluating the effects of early decompressive surgery (DECIMAL, DESTINY, HAMLET). Primary outcome was the score on the modified Rankin scale at 12 months dichotomized between modified Rankin scale 0-3 and modified Rankin scale 4-6. Secondary outcome measures were modified Rankin scale score 0-4 and survival. Risk ratios were adjusted with Poisson regression. Results Mean patient age was 48 years. Median time from stroke onset to hemicraniectomy was 23.5 h in both treatment groups. Treatment with hypothermia had no effect on the primary outcome (modified Rankin scale 0-3 versus 4-6 (13/53 (25%) versus 24/58 (41%)); adjusted risk ratio 0.66, 95% confidence interval 0.38-1.13). Fewer patients treated with hypothermia had a modified Rankin scale score of 0-4 (21/53 (40%) versus 42/58 (72%); adjusted risk ratio 0.53, 95% confidence interval 0.37-0.76) and fewer patients survived (26/53 (49%) versus 46/58 (79%); adjusted risk ratio 0.60, 95% confidence interval 0.44-0.82). Conclusions In patients with space-occupying cerebral infarction, treatment with hypothermia had no additional benefit on functional outcome compared with treatment with hemicraniectomy alone.

Clinical Significance of J Waves in Patients Undergoing Therapeutic Hypothermia for Out-of-Hospital Cardiac Arrest.

Hypothermia is associated with the development of J waves. However, little is known about the impact of these electrocardiogram (ECG) findings on the development of ventricular arrhythmias and patient outcomes during therapeutic hypothermia (TH) postresuscitation from out-of-hospital cardiac arrest (OHCA). We investigated the prevalence of J waves in OHCA patients prior to and during TH. Additionally, we explored the incidence of atrial and ventricular arrhythmias and in-hospital mortality for patients with and without J waves either at baseline, during TH, or both. We conducted a retrospective analysis of patients who suffered OHCA and underwent TH (goal temperature of 32-34°C). Fifty-nine patients were stratified dependent upon the presence of or the development of J waves on surface ECGs. Descriptive analysis and logistic regression modeling were used to assess the population differences and mortality, respectively, between patients who developed J waves during TH and those who did not. There was no difference in the development of in-hospital atrial or ventricular arrhythmias between patients with J waves present during TH (16%) and those without (17.6%, P = 0.834). Compared to patients without J waves at baseline and during TH, those with J waves present both at baseline and during TH had significantly worse survival (hazard ratio = 12.42, P = 0.046). While J waves are common ECG findings during TH in patients resuscitated from OHCA, our study demonstrated an increase in mortality for patients with J waves present both at baseline and during TH.

Timing of Percutaneous Coronary Intervention and Therapeutic Hypothermia in Patients With ST-Elevation Myocardial Infarction and Out-of-hospital Cardiac Arrest.

The American College of Cardiology/American Heart Association guidelines include a Class 1 recommendation to initiate therapeutic hypothermia (TH) in comatose patients with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who have achieved return of spontaneous circulation. There is also a Class 1 recommendation for immediate angiography in these patients whose initial electrocardiography shows ST-elevation myocardial infarction (STEMI). However, due to a lack of clinical trials evaluating these patients who have received both percutaneous coronary intervention (PCI) and TH, controversy remains regarding whether the two can be safely combined. Furthermore, in patients who receive TH and PCI, another question to address is which therapy to initiate first. This article focuses on how best to manage comatose OHCA survivors who have an initial shockable rhythm and STEMI.

重症くも膜下出血患者に対する血管内冷却カテーテルによる体温管理の可能性と安全性について ─低体温療法から復温後の常温管理に関する初期経験─

Fever in subarachnoid hemorrhage (SAH) is associated with vasospasm and poor outcome. To mitigate early brain damage in SAH, we have been treating World Federation of Neurological Surgeons (WFNS) Grade 5 patients with rapid induction of therapeutic hypothermia (TH) initiated immediately following onset of SAH and continued for approximately 7 days. Management after rewarming has been problematic. Rebound fever, especially during the period of post-SAH vasospasm, may increase the risk of cerebral infarction. We prospectively studied the feasibility and safety of endovascular cooling for maintaining prophylactic normothermia following initial TH in patients with severe SAH.TH (core body temperature 34.0°C) using surface cooling was initiated immediately after a diagnosis of WFNS Grade 5 SAH was made. All ruptured aneurysms were surgically clipped as soon as possible within 6 hours after arrival. At approximately postoperative day 7, after rewarming to 36°C, an endo- vascular catheter with 2 cooling balloons (Cool Line® Catheter, Asahi Kasei ZOLL Medical Corp., Tokyo, Japan) was inserted into the left internal jugular vein and connected to the Thermogard XP® Temperature Management System (Asahi Kasei ZOLL Medical Corp.) for the following 7 days. Temperature recordings in 11 SAH patients immediately before the period of endovascular cooling served as the control.Eleven patients (6 women; mean age of 63.8 ± 6.4 years [range, 50-73 years]) were enrolled in the study. Endovascular cooling was initiated at 7.9 ± 1.4 days (range, 6-11 days) after admission and continued for 6.7 ± 0.9 days (range 4-7 days). Unfavorable outcomes were associated with minimal shivering and good temperature control, whereas favorable outcomes were associated with vigorous shivering and increased temperature. Nine patients manifested shivering with increased temperature and were treated with acetaminophen, dexmedetomidine, and/or propofol. During the study period, two patients developed fevers above 38°C, and 8 of 11 patients without endovascular cooling developed fevers (p=0.03, two-tailed Fisher's exact test). There was no evidence of cerebral infarction related to vasospasm during endovascular cooling, and no catheter-related sepsis or thromboembolic events. In one patient, fasudil hydrochloride was administered intra-arterially for angiographic vasospasm, resulting in no cerebral infarction. In another patient, intensive treatment was withdrawn because of massive brain swelling; however, slight but extensive early ischemic change was retrospectively confirmed on computed tomography prior to endovascular cooling. Vasospasm-related cerebral infarction occurred in one patient 2 days after removal of the cooling catheter. In one patient, fatal bacterial meningitis related to spinal drainage occurred on Day 29. Three-month outcomes showed good recovery in 2, moderate disability in 4, severe disability in 2, vegetative state in 1, and death in 2. Amelioration of fever burden during the first 14 days after onset of SAH was safe and feasible with combined surface and endovascular cooling in patients with WFNS Grade 5 SAH.

Feasibility and Safety of Mild Therapeutic Hypothermia in Poor-Grade Subarachnoid Hemorrhage: Prospective Pilot Study.

Therapeutic hypothermia (TH) improves the neurological outcome in patients after cardiac arrest and neonatal hypoxic brain injury. We studied the safety and feasibility of mild TH in patients with poor-grade subarachnoid hemorrhage (SAH) after successful treatment. Patients were allocated randomly to either the TH group (34.5°C) or control group after successful clipping or coil embolization. Eleven patients received TH for 48 hours followed by 48 hours of slow rewarming. Vasospasm, delayed cerebral ischemia (DCI), functional outcome, mortality, and safety profiles were compared between groups. We enrolled 22 patients with poor-grade SAH (Hunt & Hess Scale 4, 5 and modified Fisher Scale 3, 4). In the TH group, 10 of 11 (90.9%) patients had a core body temperature of < 36°C for > 95% of the 48-hour treatment period. Fewer patients in the TH than control group (n = 11, each) had symptomatic vasospasms (18.1% vs. 36.4%, respectively) and DCI (36.3% vs. 45.6%, respectively), but these differences were not statistically significant. At 3 months, 54.5% of the TH group had a good-to-moderate functional outcome (0–3 on the modified Rankin Scale [mRS]) compared with 9.0% in the control group (P = 0.089). Mortality at 1 month was 36.3% in the control group compared with 0.0% in the TH group (P = 0.090). Mild TH is feasible and can be safely used in patients with poor-grade SAH. Additionally, it may reduce the risk of vasospasm and DCI, improving the functional outcomes and reducing mortality. A larger randomized controlled trial is warranted.

Time to Awakening Is Often Delayed in Patients Who Receive Targeted Temperature Management After Cardiac Arrest.

Post cardiac arrest, neuroprognostication remains a complex and clinically challenging issue for critical care providers. For this reason, our primary objective in this study was to determine the frequency of survival and favorable neurological outcomes in post-cardiac arrest patients with delayed time to awakening. To assess whether early withdrawal of care may adversely impact survival, we also sought to describe the time to withdrawal of care of non-surviving patients. We performed a retrospective study of patients resuscitated after cardiac arrest in two large academic community hospitals. We performed a structured chart review of patients treated with therapeutic hypothermia (TH) at one hospital from 2009 to 2015 and at a second hospital from 2013 to 2015. Demographics and Utstein style variables were recorded on all patients, as well as temporal variables to characterize the time interval from Return of Spontaneous Circulation (ROSC) to awakening as recorded by ICU nurses and defined as Glasgow Coma Scale (GCS) of >8. Descriptive data were also captured regarding time to withdrawal of care. We pre-hoc defined delayed awakening as >72 hours post ROSC or >72 hours post rewarming. Our primary outcome was survival to hospital discharge with a secondary outcome of a favorable cerebral performance category of 1 or 2. During this study period, 321 patients received TH, with 111 (34.6%) discharged alive and, of these, 67 (68.5%) experienced a good neurological outcome. Awakening more than 72 hours after return of circulation was common with 31 patients surviving to discharge. Of these, 16 of 31 (51.6%) were found to have a good neurological outcome on hospital discharge. Of the patients who died before discharge, 54 (29.5%) had care withdrawn less than 72 hours after ROSC. A delayed time to awakening is not infrequently associated with a good neurological outcome after TH in patients resuscitated from cardiac arrest.

Clinical Effect of Rebound Hyperthermia After Cooling Postcardiac Arrest: A Retrospective Cohort Study.

Therapeutic hypothermia is used in select patients after out-of-hospital cardiac arrest (OHCA) to improve neurologic outcome. Rebound hyperthermia (RH) is commonly observed post-treatment. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this study is to examine the impact of RH after completion of therapeutic hypothermia in patients postcardiac arrest. We analyzed a retrospective cohort from our institution. All adults who underwent therapeutic hypothermia post-OHCA were divided into two cohorts depending on the presence/absence of fever (T > 38°C) within 24 hours of completing hypothermia protocol. Clinical outcomes were analyzed at hospital discharge or death. Among 306 patients admitted with OHCA, 117 underwent hypothermia, 97 survived 24 hours postrewarming. Twenty-seven patients (50%) with RH died compared with 20 (47%) without RH (OR, 1.15; 95% CI, 0.52-2.57). Twenty-six patients (67%) with RH had a poor neurologic outcome compared with 27 (63%) without RH (OR 1.19, 95% CI, 0.51-2.74). RH is common after completion of therapeutic hypothermia in comatose patients due to cardiac arrest and is associated with poor neurologic outcomes. We found no significant clinical impact of rebound hypothermia on neurologic outcome or mortality, but our study was underpowered to reveal such impact if it exists.

Editor's Choice- Inside the cold heart: A review of therapeutic hypothermia cardioprotection.

Targeted temperature management has been originally used to reduce neurological injury and improve outcome in patients after out-of-hospital cardiac arrest. Myocardial infarction remains a major cause of death in the world and several investigators are studying the effect of mild therapeutic hypothermia during an acute cardiac ischemic injury. A search on MEDLINE, Scopus and EMBASE databases was conducted to obtain data regarding the cardioprotective properties of therapeutic hypothermia. Preclinical studies have shown that therapeutic hypothermia provides a cardioprotective effect in animals. The proposed pathways for the cardioprotective effects of therapeutic hypothermia include stabilization of mitochondrial permeability, production of nitric oxide, equilibration of reactive oxygen species, and calcium channels homeostasis. Clinical trials in humans have yielded controversial results. Current trials are therefore seeking to combine therapeutic hypothermia with other treatment modalities in order to improve the outcomes of patients with acute ischemic injury. This article provides a review of the hypothermia effects on the cardiovascular system, from the basic science of physiological changes in the human body and molecular mechanisms of cardioprotection to the bench of clinical trials with therapeutic hypothermia in patients with acute ischemic injury.

Therapeutic hypothermia in patients following traumatic brain injury: a systematic review.

The efficacy of therapeutic hypothermia in adult patients with traumatic brain injury is not fully understood. The historical use of therapeutic hypothermia at extreme temperatures was associated with severe complications and led to it being discredited. Positive results from animal studies using milder temperatures led to renewed interest. However, recent studies have not convincingly demonstrated the beneficial effects of therapeutic hypothermia in practice. This review aims to answer the question: in adults with a severe traumatic brain injury (TBI), does the use of therapeutic hypothermia compared with normothermia affect neurological outcome? Systematic review. Four major electronic databases were searched, and a hand search was undertaken using selected key search terms. Inclusion and exclusion criteria were applied. The studies were appraised using a systematic approach, and four themes addressing the research question were identified and critically evaluated. A total of eight peer-reviewed studies were found, and the results show there is some evidence that therapeutic hypothermia may be effective in improving neurological outcome in adult patients with traumatic brain injury. However, the majority of the trials report conflicting results. Therapeutic hypothermia is reported to be effective at lowering intracranial pressure; however, its efficacy in improving neurological outcome is not fully demonstrated. This review suggests that therapeutic hypothermia had increased benefits in patients with haematoma-type injuries as opposed to those with diffuse injury and contusions. It also suggests that cooling should recommence if rebound intracranial hypertension is observed. Although the data indicates a trend towards better neurological outcome and reduced mortality rates, higher quality multi-centred randomized controlled trials are required before therapeutic hypothermia is implemented as a standard adjuvant therapy for treating traumatic brain injury. Therapeutic hypothermia can have a positive impact on patient outcome, but more research is required.

Therapeutic Hypothermia for Patients with Out-of-Hospital Cardiac Arrest in North Carolina

Introduction: While therapeutic hypothermia has been the standard of care for patients who suffer out-of-hospital cardiac arrest (OHCA), recent trials have led to an advisory statement recommending a focus on targeted in-hospital temperature management and against initiation of prehospital hypothermia with rapid infusion of cooled saline. The aim of this study is to review the experience with therapeutic hypothermia in North Carolina. Methods: We studied patients who suffered OHCA in North Carolina in 2012 captured in the CARES database as part of the Heart Rescue Project. We excluded patients without return of spontaneous circulation and patients without an advanced airway placed in the field to reduce selection bias. Bivariate distributions and multivariate logistic regression models were used to examine differences in survival to discharge and positive neurological outcome. Results: 847 patients were included in the analysis of pre-hospital hypothermia. Of these patients, 55% received prehospital hypothermia. Prehospital initiation of hypothermia was associated with higher survival to hospital discharge (OR 1.55, 95% CI 1.03–2.32) and improved neurologic outcome at discharge (OR 1.56 95% CI 1.01–2.40). In patients who survived to hospital admission (n = 537), in-hospital hypothermia was associated with a non-significant trend toward better survival to discharge (p = 0.18). Conclusion: We found that patients who received prehospital hypothermia had improved outcomes, a finding that may be due to a greater likelihood of receiving in-hospital hypothermia or a reflection of higher quality of pre-hospital care. These findings support ongoing efforts to improve all aspects of the chain of survival after cardiac arrest.

The effects of therapeutic hypothermia in patients in ROSC (Return of Spontaneous Circulation): Appropriate or ineffective treatment? A literature critical review

The effects of therapeutic hypothermia in patients in ROSC (Return of Spontaneous Circulation): Appropriate or ineffective treatment? A literature critical review

Mild therapeutic hypothermia in patients resuscitated from out-of-hospital cardiac arrest: A meta-analysis of randomized controlled trials.

Aims:Guidelines recommend mild therapeutic hypothermia (MTH) for survivors of out-of-hospital cardiac arrest (OHCA). However, there is little literature demonstrating a survival benefit. We performed a meta-analysis of randomized controlled trials (RCTs) assessing the efficacy of MTH in patients successfully resuscitated from OHCA.Materials and Methods:Electronic databases were searched for RCT involving MTH in survivors of OHCA, and the results were put through a meta-analysis. The primary endpoint was all-cause mortality, and the secondary endpoint was favorable neurological function. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using the Mantel–Haenszel method. A fixed-effect model was used and, if heterogeneity (I2) was >40, effects were analyzed using a random model.Results:Six RCT (n = 1400 patients) were included. Overall survival was 50.7%, and favorable neurological recovery was 45.5%. Pooled data demonstrated no significant all-cause mortality (OR, 0.81; 95% CI 0.55–1.21) or neurological recovery (OR, 0.77; 95% CI 0.47–1.24). No evidence of publication bias was observed.Conclusion:This meta-analysis demonstrated that MTH did not confer benefit on overall survival rate and neurological recovery in patients resuscitated from OHCA.

The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm.

Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms. We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH. Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms.

Shivering management during therapeutic hypothermia in patients with traumatic brain injury: protocol from the Eurotherm3235 trial

Effective hypothermia in critical care requires a strategy to prevent and manage shivering. Core body temperature in mammals is highly regulated [1]. Hypothermia leads to the activation of measures to counteract this, reducing heat loss through vasoconstriction and increasing heat generation through increased metabolism and shivering. Shivering resists the reduction in core temperature but also increases physiological stresses, including an increase in oxygen demand, catecholamine release and hypertension. It also can appear distressing, may be confused with seizure activity and generally results in monitoring being more difficult. In the Eurotherm3235 trial [2], the prevention of shivering required that patients were prepared for hypothermia appropriately, that shivering was detected early and that a plan to treat shivering was followed should it be detected. Patients were sedated with an opiate, propofol and/or midazolam because anesthetic agents have been shown to reduce the core temperature set point for shivering. Regular paracetamol was also prescribed as this reduces the hypothalamic temperature set point. The hands and feet of patients were covered with towels, which in addition to reducing the risk of thermal burns has been shown to suppress shivering [3]. During hypothermia, patients were observed closely for signs of shivering, particularly in the jaw, neck and trunk as these areas area the earliest to show signs of shivering [4]. On detection of possible shivering, seizures and inadequate sedation were excluded as causes of muscle movements. Specific interventions included active skin counter-warming with forced air convection as mean skin temperature contributes around 20% to the control

An inspection of therapeutic hypothermia preceding coronary reperfusion in patients with a cardiogenic shock complicating anterior ST-segment elevation myocardial infarction

BackgroundWe retrospectively investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural therapeutic hypothermia may have clinical advantages in patients with a profound cardiogenic shock complicating anterior ST-segment elevation myocardial infarction (STEMI). MethodsOf 483 consecutive patients treated with PCI for a first anterior STEMI including 31 patients with aborted sudden cardiac arrest between 2009 and 2013, a total of 37 consecutive patients with an anterior STEMI complicated with profound cardiogenic shock defined as the presence of hyperlactic acidemia (serum levels of lactate >4mmol/L) with mechanical circulatory support were identified. An impaired myocardial tissue-level reperfusion (angiographic myocardial blush grade 0 or 1) and in-hospital mortality were evaluated in accordance with the presence or absence of pre-PCI procedural therapeutic hypothermia. ResultsThirteen patients were treated with pre-PCI procedural therapeutic hypothermia and 24 were not inducted with therapeutic hypothermia. Five patients with and 18 without pre-PCI procedural therapeutic hypothermia impaired myocardial tissue-level reperfusion (38% vs. 75%, p=0.037). A total of 26 patients with in-hospital death (overall in-hospital mortality 70%) were composed of 6 with and 20 without therapeutic hypothermia (in-hospital mortality 46% vs. 83%, p=0.028). A multivariate analysis demonstrated a significant association of pre-PCI procedural therapeutic hypothermia (p=0.021) with in-hospital survival benefit. Adverse events associated with therapeutic hypothermia were not found in 12 patients who completed this treatment. ConclusionsThe present study may imply a crucial possibility of clinical benefits of pre-PCI procedural therapeutic hypothermia in patients with a cardiogenic shock complicating anterior STEMI.

Safety of therapeutic hypothermia in children on veno-arterial extracorporeal membrane oxygenation after cardiac surgery.

The aim of this study was to evaluate whether the use of therapeutic hypothermia in patients receiving extracorporeal membrane oxygenation after paediatric cardiac surgery is associated with increased complication rates. We undertook a retrospective study to compare the complication rates and clinical course of children after cardiac surgery in two groups – extracorporeal membrane oxygenation without therapeutic hypothermia (group 1) and extracorporeal membrane oxygenation with therapeutic hypothermia (group 2). Therapeutic hypothermia was performed via the extracorporeal membrane oxygenation circuit heater-cooler device. A total of 96 patients were included in this study (59 in group 1 and 37 in group 2). Complications were comparable between group 1 and group 2, except that more patients with therapeutic hypothermia had hypertension while on extracorporeal membrane oxygenation. Therapeutic hypothermia was not independently associated with in-hospital mortality (adjusted odds ratio 1.16, 95% CI: 0.33-4.03; p=0.82). Therapeutic hypothermia can be safely provided to children on extracorporeal membrane oxygenation after cardiac surgery without an increase in complication rates.

Effect of therapeutic hypothermia on C-reactive protein levels in patients with perinatal asphyxia.

To determine the changes in serum C-reactive protein (CRP) levels during therapeutic hypothermia. Between January 2011 and June 2013, 133 hypoxic-ischemic encephalopathy patients being followed up in the neonatal intensive care unit of Dr. Sami Ulus Maternity and Children's Hospital are prospectively evaluated. Group 1; patients that received therapeutic hypothermia (n = 74) and group 2; patients that did not required therapeutic hypothermia (n = 59). All the patients underwent serial complete blood cell count and CRP assessments; blood cultures were obtained from all the cases at the time of admission and when CRP levels were elevated. Positive blood cultures were encountered in five cases (6.7%) in group 1 while no blood culture-proven septicemia was encountered in group 2. The CRP levels elevated gradually reaching a peak level on the 4th day and then decreased during the therapeutic hypothermia in patients with no blood culture-proven septicemia in group 1. The CRP levels showed statistically significant changes reaching a peak level on the 7th day in patients with blood culture-proven septicemia in group 2. Also, the CRP levels showed no alteration with time in group 2. Therapeutic hypothermia itself might be associated with CRP elevation rather than an actual infection.