Use Of Targeted Temperature Management Research Articles

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.

The role of targeted temperature management in 30-day hospital readmissions in cardiac arrest survivors: A national population-based study.

Targeted temperature management (TTM) implementation following resuscitation from cardiac arrest is controversial. Although prior studies have shown that TTMimproves neurological outcomes and mortality, less is known about the rates or causes of readmission in cardiac arrest survivors within 30days. We aimed to determine whether the implementation of TTM improves all-cause 30-day unplanned readmission rates in cardiac arrest survivors. Using the Nationwide Readmissions Database, we identified 353,379 adult cardiac arrest index hospitalizations and discharges using the International Classification of Diseases, 9thand 10thcodes. The primary outcome was 30-day all-cause unplanned readmissions following cardiac arrest discharge. Secondary outcomes included 30-day readmission rates and reasons, including impacts on other organ systems. Of 353,379 discharges for cardiac arrest with 30-day readmission,9,898 (2.80%) received TTM during index hospitalization. TTM implementation was associated with lower 30-day all-cause unplanned readmission rates versus non-recipients(6.30% vs. 9.30%, p<0.001). During index hospitalization, receiving TTM was also associated with higher rates of AKI (41.12% vs. 37.62%, p<0.001) and AHF (20.13% vs. 17.30%, p<0.001). We identified an association between lower rates of 30-day readmission for AKI (18.34% vs. 27.48%, p<0.05) and trend toward lower AHF readmissions (11.32% vs. 17.97%, p=0.05) among TTM recipients. Our study highlights a possible negative association between TTM and unplanned 30-day readmission in cardiac arrest survivors, thereby potentially reducing the impact and burden of increased short-term readmission in these patients. Future randomized studies are warranted to optimize TTM use during post-arrest care.

Abstract 11625: To Cool or Not to Cool for Brugada Syndrome

Brugada syndrome (BrS) is an autosomal dominant genetic disorder, characterized by abnormal findings on the electrocardiogram (ECG) in conjunction with an increased risk of ventricular tachycardia (VT) and sudden cardiac death. Triggers of the ECG pattern and VT in BrS include fevers, drugs, and electrolyte abnormalities. This case reports a unique treatment approach of targeted temperature management (TTM) to treat persistent fevers and VT secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a patient with BrS. We report the case of a 23 year old male with history of BrS with an intracardiac defibrillator (ICD) who presented to the hospital with chest pain and a runny nose. Vital signs upon admission were notable for temperature of 38.2 o C, heart rate of 155 beats/minute and blood pressure of 134/110 mmHG. Laboratory values on admission revealed a normal complete blood count, a normal basic metabolic panel, an elevated c-reactive protein (CRP) of 19.1, and PCR confirmed SARS-CoV-2 infection, with a cycle threshold value of 16.4. ECG revealed a type 2 Brugada pattern. Interrogation of his ICD revealed 28 device shocks on the morning of admission, with each episode beginning with a premature ventricular contraction inciting polymorphic VT. His transthoracic echocardiogram (TTE) discovered a newly reduced ejection fraction of 25% with global hypokinesis. Persistent VT prompted intubation and sedation with propofol. Repeat SARS-CoV-2 inflammatory markers revealed a rising CRP of 244. Therapies included acetaminophen around the clock and remdesivir and dexamethasone to target COVID-19. During the first two days in the cardiac intensive care unit (CICU), fevers persisted with Brugada pattern on ECG. Given the potential for recurrent VT, targeted TTM was initiated using the Arctic Sun external cooling device to maintain normothermia to 37 o C. After 5 days of no VT, fever curve, Brugada pattern, and inflammatory markers improved. TTM was discontinued, COVID-19 therapies were completed, and he was extubated. His cardiac function normalized on repeat TTE and he was discharged home. We report a unique case of TTM use in a patient with BrS with VT secondary to infection with COVID-19, as a way to decrease fevers and prevent further triggering of VT.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

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.

Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BackgroundTargeted temperature management (TTM) is a vital element of postresuscitation management after cardiac arrest. Though international guidelines recommend TTM, the supporting evidence is of low certainty.Aims and objectivesTo estimate the effect of TTM strategy on mortality and neurological outcomes in postcardiac arrest survivors.Materials and methodsRandomized controlled trials (RCTs) published in English evaluating the use of TTM in adult comatose survivors of cardiac arrest were included. Studies were categorized into two groups, based on hypothermia vs normothermia. The main outcome was death due to any origin. The secondary outcome measures evaluated neurological outcome and complications associated with TTM. Outcomes were analyzed by calculating Odds Ratio (OR) of a worse outcome. ORs with 95% CIs in a forest plot were used to show the results of random-effects meta-analyses.ResultsOn pooled analysis of 11 RCTs, no difference was observed in death due to any origin rates in the hypothermia compared to the normothermia group (OR; 0.88, 95% CI: 0.39–1.16). Overall, no difference in poor neurological outcome was observed between the two groups (OR; 0.86, 95% CI: 0.66–1.12). Trial sequencing analysis for mortality and poor neurological outcome showed that number to achieve power to predict futility has been achieved in both the parameters.ConclusionsThis meta-analysis showed that hypothermia compared to normothermia TTM strategies does not improve survival or neurologic outcomes.How to cite this articleMishra SB, Patnaik R, Rath A, Samal S, Dash A, Nayak B. Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(4):506–513.

Contemporary targeted temperature management: Clinical evidence and controversies.

Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.

Target temperature management following cardiac arrest: a systematic review and Bayesian meta-analysis

BackgroundTemperature control with target temperature management (TTM) after cardiac arrest has been endorsed by expert societies and adopted in international clinical practice guidelines but recent evidence challenges the use of hypothermic TTM.MethodsSystematic review and Bayesian meta-analysis of clinical trials on adult survivors from cardiac arrest undergoing TTM for at least 12 h comparing TTM versus no TTM or with a separation > 2 °C between intervention and control groups using the PubMed/MEDLINE, EMBASE, CENTRAL databases from inception to 1 September 2021 (PROSPERO CRD42021248140). All randomised and quasi-randomised controlled trials were considered. The risk ratio and 95% confidence interval for death (primary outcome) and unfavourable neurological recovery (secondary outcome) were captured using the original study definitions censored up to 180 days after cardiac arrest. Bias was assessed using the updated Cochrane risk-of-bias for randomised trials tool and certainty of evidence assessed using the Grading of Recommendation Assessment, Development and Evaluation methodology. A hierarchical robust Bayesian model-averaged meta-analysis was performed using both minimally informative and data-driven priors and reported by mean risk ratio (RR) and its 95% credible interval (95% CrI).ResultsIn seven studies (three low bias, three intermediate bias, one high bias, very low to low certainty) recruiting 3792 patients the RR by TTM 32–34 °C was 0.95 [95% CrI 0.78—1.09] for death and RR 0.93 [95% CrI 0.84—1.02] for unfavourable neurological outcome. The posterior probability for no benefit (RR ≥ 1) by TTM 32–34 °C was 24% for death and 12% for unfavourable neurological outcome. The posterior probabilities for favourable treatment effects of TTM 32–34 °C were the highest for an absolute risk reduction of 2–4% for death (28–53% chance) and unfavourable neurological outcome (63–78% chance). Excluding four studies without active avoidance of fever in the control arm reduced the probability to achieve an absolute risk reduction > 2% for death or unfavourable neurological outcome to ≤ 50%.ConclusionsThe posterior probability distributions did not support the use of TTM at 32–34 °C compared to 36 °C also including active control of fever to reduce the risk of death and unfavourable neurological outcome at 90–180 days. Any likely benefit of hypothermic TTM is smaller than targeted in RCTs to date.

Цільовий температурний менеджмент у комплексі інтенсивної терапії важкої черепно-мозкової травми

Актуальність. Гіпертермія викликає церебральне пошкодження і погіршує неврологічне відновлення при важкій черепно-мозковій травмі (ЧМТ). Метою роботи було вивчення неврологічних наслідків у пацієнтів з тяжкою ЧМТ та рефрактерною к фармакологічній корекції гіпертермією при використанні цільового температурного менеджменту з залученням езофагеального охолоджувального пристрою в комплексі інтенсивної терапії порівняно з групою контролю. Матеріали та методи. Обстежено 20 пацієнтів віком від 23 до 54 років із діагнозом «важка ЧМТ». Пацієнти були розподілені на 2 групи: пацієнтам I групи (n = 10) здійснювався стандартний комплекс інтенсивної терапії, що базується на міжнародних рекомендаціях щодо менеджменту важкої ЧМТ (2007, 2016 рр.); у II групі (n = 10) у стандартний комплекс інтенсивної терапії було включено цільовий температурний менеджмент (ЦТМ) за допомогою гіпотерма «Blanketrol II» (CSZ, США) і езофагеального пристрою для охолодження (Esophageal Cooling Device, ACT, США) з метою досягнення нормотермії у діапазоні 36,5–37 °С. У всіх пацієнтів оцінювався неврологічний статус за шкалою коми Глазго на наступних етапах: початково, на 5-ту, 10-ту добу та на момент виписки з лікувального закладу. Наслідки перенесеної ЧМТ визначалися за шкалою СРС (Сerebral Performance Categories), з оцінкою максимального балу при знаходженні у відділенні реанімації та інтенсивної терапії (ВРІТ) та на момент виписки з лікувального закладу. Результати. Аналіз динаміки неврологічного відновлення при виписці з лікувального закладу виявив достовірне поліпшення в групі пацієнтів із застосуванням ЦТМ, що знайшло відображення у середньому значенні за шкалою коми Глазго 13,50 ± 1,36 бала порівняно з 11,5 ± 1,8 бала в контрольній групі (p &lt; 0,05). При аналізі кращих значень за шкалою СРС в період знаходження пацієнтів в умовах ВРІТ добре неврологічне відновлення, що відповідало СРС 1–2, було отримано у 20 та 50 %, погане на рівні СРС 3–4 — у 70 і 50 % пацієнтів у контрольній та групі із застосуванням ЦТМ відповідно. При виписці з лікувального закладу неврологічне відновлення на рівні СРС 1–2 було виявлено у 30 % порівняно з 80 %, на рівні СРС 3–4 — у 70 % порівняно з 20 % пацієнтів у контрольній і групі із застосуванням ЦТМ відповідно. Міжгрупові відмінності середніх значень за шкалою СРС на момент виписки з лікувального закладу мали вірогідний характер та становили 2,90 ± 0,94 і 2,00 ± 0,77 (Р = 0,02) в контрольній і основній групах відповідно. Висновки. Використання цільового температурного менеджменту з метою забезпечення нормотермії створює сприятливі умови для більш повного відновлення порушених неврологічних функцій після важкої черепно-мозкової травми.

Serum Neuron-Specific Enolase Thresholds for Predicting Postcardiac Arrest Outcome: A Systematic Review and Meta-analysis.

To determine thresholds of serum neuron-specific enolase (NSE) for prediction of poor outcome after cardiac arrest with >95% specificity using a unique method of multiple thresholds meta-analysis. Data from a systematic review by the European Resuscitation Council (ERC 2014) were updated with literature searches from PubMed, Cochrane, and Scopus until August 2020. Search terms included the MeSH terms "heart arrest" and "biomarkers" and the text words "cardiac arrest," "neuron specific enolase," "coma" and "prognosis." Cohort studies with comatose cardiac arrest survivors aged >16 years undergoing targeted temperature management (TTM) and NSE levels within 96 hours of resuscitation were included. Poor outcome was defined as cerebral performance category 3-5 at hospital discharge or later. Studies without extractable contingency tables were excluded. A multiple thresholds meta-analysis model was used to generate summary receiver operating characteristic curves for various time points. NSE thresholds (and 95% prediction intervals) for >95% specificity were calculated. Evidence appraisal was performed using a method adapted from the American Academy of Neurology grading criteria. Data from 11 studies (n = 1,982) at 0-24 hours, 21 studies (n = 2,815) at 24-48 hours, and 13 studies (n = 2,557) at 48-72 hours was analyzed. Areas under the curve for prediction of poor outcomes were significantly larger at 24-48 hours and 48-72 hours compared to 0-24 hours (0.82 and 0.83 vs 0.64). Quality of evidence was very low for most studies because of the risk of incorporation bias-knowledge of NSE levels potentially influenced life support withdrawal decisions. To minimize falsely pessimistic predictions, NSE thresholds at the upper 95% limit of prediction intervals are reported. For prediction of poor outcome with specificity >95%, upper limits of the prediction interval for NSE were 70.4 ng/mL at 24-48 hours and 58.6 ng/mL at 48-72 hours. Sensitivity analyses excluding studies with inconsistent TTM use or different outcome criteria did not substantially alter the results. NSE thresholds for highly specific prediction of poor outcome are much higher than generally used. Future studies must minimize bias by masking treatment teams to the results of potential predictors and by prespecifying criteria for withdrawal of life support.

Variation in Post-Cardiac Arrest Care Within a Regional EMS System

Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors. Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a “good” outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables. Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals. Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG.

Efficacy of Targeted Temperature Management after Pediatric Cardiac Arrest: A Meta-Analysis of 2002 Patients.

Cardiac arrest (CA) is associated with high mortality and poor life quality. Targeted temperature management (TTM) or therapeutic hypothermia is a therapy increasing the survival of adult patients after CA. The study aim was to assess the feasibility of therapeutic hypothermia after pediatric CA. We performed a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the use of TTM after pediatric CA. The primary outcome was survival to hospital discharge or 30-day survival. Secondary outcomes included a one-year survival rate, survival with a Vineland adaptive behavior scale (VABS-II) score ≥ 70, and occurrence of adverse events. Ten articles (n = 2002 patients) were included, comparing TTM patients (n = 638) with controls (n = 1364). In a fixed-effects meta-analysis, survival to hospital discharge in the TTM group was 49.7%, which was higher than in the non-TTM group (43.5%; odds ratio, OR = 1.22; 95% confidence interval, CI: 1.00, 1.50; p = 0.06). There were no differences in the one-year survival rate or the occurrence of adverse events between the TTM and non-TTM groups. Altogether, the use of TTM was associated with a higher survival to hospital discharge; however, it did not significantly increase the annual survival. Additional high-quality prospective studies are necessary to confer additional TTM benefits.

Implementation of Targeted Temperature Management After Out-of-Hospital Cardiac Arrest: Observations From the Los Angeles County Regional System.

BackgroundDespite the benefits of targeted temperature management (TTM) for out‐of‐hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban‐suburban regional system of care.Methods and ResultsThis was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10 million residents. All adult patients aged ≥18 years with non‐traumatic out‐of‐hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67 years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non‐White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM.ConclusionsWithin this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.

Abstract 346: Targeted Temperature Management is Associated with Improved Neurological Outcomes in Witnessed Out-of-hospital Cardiac Arrest Patients Who Achieve Early Return of Spontaneous Circulation

Background: Previous randomized controlled trials demonstrated the efficacy of targeted temperature management (TTM) in out-of-hospital cardiac arrest (OHCA) patients with both shockable and non-shockable rhythm. Real-world evidence for TTM using large OHCA database are scarce, and no study has investigated the relationship between TTM and time-to-return of spontaneous circulation (ROSC). Methods: The Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry is a multicenter, prospective, observational registry including 34,754 OHCA patients between 2014 and 2017. Patients with witnessed non-traumatic OHCA who had been resuscitated and were in a coma were included. Eligible patients were divided into two groups according to the use of TTM. The primary outcome was defined as a Cerebral Performance Categories (CPC) Scale 1-2 at 30 days after OHCA. The propensity score matching analysis was used. The cubic spline analysis of the odds ratio of CPC 1-2 for TTM use by time-to-ROSC was performed. Results: Out of 34,754 patients with OHCA, 5,261 patients were included. The mean age was 70.3 years, and 3,417 (65.0%) were male. CPC 1-2 was more frequently observed in the TTM group in propensity score matching analysis (15.1% vs. 8.5%; odds ratio 1.92; 95% confidence interval 1.04-3.53; P=0.037). The cubic spline analysis showed that TTM was associated with CPC 1-2 in witnessed OHCA patients, which did not reach statistical significance in patients with time-to-ROSC longer than 50 min. Conclusions: TTM was associated with better neurological outcomes in witnessed OHCA patients, especially when patients were resuscitated within 50 min after collapse.

Abstract 310: Validation of the Cardiac Arrest Hospital Prognosis (CAHP) Score in an American Out-of-hospital Cardiac Arrest Cohort: Results From a Large Single Center Cardiac Arrest Registry

Background: The cardiac arrest hospital prognosis (CAHP) score has been shown in French studies to predict neurologic outcomes in patients who suffer an out-of-hospital cardiac arrest (OHCA), but this score has not been studied in an American cohort. We aimed to validate the CAHP score in an independent, single center, large cardiac arrest registry. Methods: Between January 2015 to June 2020 there were 925 patients who suffered OHCA and were transferred to Northeast Georgia Medical Center out of whom 450 patients survived to hospital admission. Cerebral Performance Category (CPC) score was used for assessment of neurologic outcome at discharge ranging from 1-5. The primary endpoint was poor neurologic outcome defined as CPC 3-5. Logistic regression was performed to identify independent predictors of poor neurologic outcome. Results: Included patients were mostly male 57% (256 of 450) with a mean age of 52±15. STEMI was present on 11% (51 of 450) and a shockable rhythm on 35% (150 of 450) of patients. Targeted temperature management (TTM) and a mechanical compression device (MCD) were used in 72% (327 of 450) and 74% (336 of 450) respectively. 76% (344 of 450) had a CPC of 3-5 at discharge. After adjusting for covariates, including gender, BMI, serum lactate level, witnessed arrest status, STEMI on ECG, and use of MCD and TTM, the only independent predictors of a CPC of 3-5 were CAHP score (p&lt;0.001), witnessed cardiac arrest, (p=0.039, OR: 0.45) and STEMI on admission ECG (P=0.001, OR: 0.22). Compared with CAHP&lt; 150, CAHP 150-200 and CAHP&gt;200 were associated with a 12-fold (p&lt;0.00001) and 79-fold (p&lt;0.00001) increased risk of poor neurologic outcome. Area under ROC curve for CAHP score predicting neurologic outcome was 0.92 (95% CI: 0.89-0.94). Conclusion: Here we show, for the first time, in an independent, large American cardiac arrest registry that CAHP score predicts neurologic outcomes in patients with OHCA. Further research is needed to assess how this prognostication tool would help clinicians decide on early vs. delayed invasive strategy in patients with OHCA admitted to hospitals across the U.S.

Mortality and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Patients With and Without Targeted Temperature Management in a Multiethnic Asian Population

The use of targeted temperature management (TTM) is increasing although adoption is still variable. We describe our 6-year experience and compare the mortality and neurological outcomes of out-of-hospital cardiac arrest (OHCA) patients with and without the use of TTM in a multiethnic Asian population. We performed a retrospective observational study at a tertiary academic medical centre. OHCA survivors admitted to our hospital between April 2010‒December 2016 were included. Outcomes of interest were 30-day mortality postresuscitation, Cerebral Performance Category (CPC) and Overall Performance Category (OPC) scores. A total of 121 of 261 patients (46.3%) underwent TTM. TTM patients were younger (TTM 60.0 years old vs no TTM 63.7 years old, P = 0.047). There was no difference in the initial arrest rhythm of shockable origin between the 2 groups (P = 0.289). There was suggestion of lower 30-day mortality (TTM 24.3% vs no TTM 31.4%, P = 0.214), higher and good CPC/OPC scores (TTM 19.0% vs no TTM 15.7%, P = 0.514) with TTM although this did not reach statistical significance. On multivariable logistic regression analysis, TTM was not associated with 30-day mortality (P = 0.07). However, older age, initial non-shockable rhythm and increased duration from arrest to return of spontaneous circulation were associated with increased mortality. Malay ethnicity was associated with a poorer CPC/ OPC score. Adoption and outcomes of TTM postresuscitation is variable and there is still a need to optimise management of the identified predictors of survival and good neurological outcomes while TTM is being used.

Temporal trends in the use of targeted temperature management after cardiac arrest and association with outcome: insights from the Paris Sudden Death Expertise Centre

PurposeRecent doubts regarding the efficacy may have resulted in a loss of interest for targeted temperature management (TTM) in comatose cardiac arrest (CA) patients, with uncertain consequences on outcome. We aimed to identify a change in TTM use and to assess the relationship between this change and neurological outcome.MethodsWe used Utstein data prospectively collected in the Sudden Death Expertise Center (SDEC) registry (capturing CA data from all secondary and tertiary hospitals located in the Great Paris area, France) between May 2011 and December 2017. All cases of non-traumatic OHCA patients with stable return of spontaneous circulation (ROSC) were included. After adjustment for potential confounders, we assessed the relationship between changes over time in the use of TTM and neurological recovery at discharge using the Cerebral Performance Categories (CPC) scale.ResultsBetween May 2011 and December 2017, 3925 patients were retained in the analysis, of whom 1847 (47%) received TTM. The rate of good neurological outcome at discharge (CPC 1 or 2) was higher in TTM patients as compared with no TTM (33% vs 15%, P < 0.001). Gender, age, and location of CA did not change over the years. Bystander CPR increased from 55% in 2011 to 73% in 2017 (P < 0.001) and patients with a no-flow time longer than 3 min decreased from 53 to 38% (P < 0.001). The use of TTM decreased from 55% in 2011 to 37% in 2017 (P < 0.001). Meanwhile, the rate of patients with good neurological recovery remained stable (19 to 23%, P = 0.76). After adjustment, year of CA occurrence was not associated with outcome.ConclusionsWe report a progressive decrease in the use of TTM in post-cardiac arrest patients over the recent years. During this period, neurological outcome remained stable, despite an increase in bystander-initiated resuscitation and a decrease in “no flow” duration.

Modeling selective therapeutic hypothermia in case of acute ischemic stroke using a 1D hemodynamics model and a simplified brain geometry.

Therapeutic hypothermia (TH) is an approved neuroproctetive treatment to reduce neurological morbidity and mortality after hypoxic-ischemic damage related to cardiac arrest and neonatal asphyxia. Also in the treatment of acute ischemic stroke (AIS), which in Western countries still shows a very high mortality rate of about 25 %, selective mild TH by means of Targeted Temperature Management (TTM) could potentially decrease final infarct volume. In this respect, a novel intracarotid blood cooling catheter system has recently been developed, which allows for combined carotid blood cooling and mechanical thrombectomy (MT) and aims at selective mild TH in the affected ischemic brain (core and penumbra). Unfortunately, so far direct measurement and control of cooled cerebral temperature requires invasive or elaborate MRI-assisted measurements. Computational modeling provides unique opportunities to predict the resulting cerebral temperatures on the other hand. In this work, a simplified 3D brain model was generated and coupled with a 1D hemodynamics model to predict spatio-temporal cerebral temperature profiles using finite element modeling. Cerebral blood and tissue temperatures as well as the systemic temperature were analyzed for physiological conditions as well as for a middle cerebral artery (MCA) M1 occlusion. Furthermore, vessel recanalization and its effect on cerebral temperature was analyzed. The results show a significant influence of collateral flow on the cooling effect and are in accordance with experimental data in animals. Our model predicted a possible neuroprotective temperature decrease of 2.5 ℃ for the territory of MCA perfusion after 60 min of blood cooling, which underlines the potential of the new device and the use of TTM in case of AIS.

Targeted Temperature Management for In-Hospital Cardiac Arrest: 6 Years of Experience.

Targeted temperature management (TTM) is widely used for postcardiac arrest management of patients with out-of-hospital cardiac arrest. However, the use of TTM for patients with in-hospital cardiac arrest (IHCA) is controversial. The aim of this study was to investigate the role of TTM in the management of patients with IHCA. The medical records of all IHCA patients who were resuscitated and returned to spontaneous circulation from January 2011 to December 2016 were reviewed. After excluding patients with new do not resuscitate orders and those who died within 24 hours, 262 patients were eligible for analysis. Thirty-five of the 262 patients (13.3%) received TTM after IHCA. Patients who received TTM and standard supportive care (SSC) had similar baseline epidemiological status. The TTM patients were older and had a longer cardiac pulmonary resuscitation duration; however, the differences were not statistically significant. The 28-day survival rate was not significantly different between groups (12/35 in the TTM group [34%] vs. 114/225 in the SSC group [50%], p = 0.079). In the patients with good neurological status before arrest (Glasgow-Pittsburgh cerebral performance category [GP-CPC] scores: 1-2), there was no significant difference in the 28-day survival between groups (11/26 in the TTM group [42.3%] vs. 81/154 [52.6%] in the SSC group; p = 0.332). In this subgroup, the TTM patients had poorer neurological outcomes at discharge (GP-CPC score 1-2) than the SSC patients (1/26 in the TTM group [3.8%] vs. 57/154 in the SSC group [37%]; p = 0.001). TTM was not associated with better 28-day survival than usual care among the patients with IHCA in this study, and the TTM patients had less favorable neurological outcomes at discharge. Randomized clinical trials are needed to assess the efficacy of TTM for IHCA patients.

Abstract 216: Renal Failure After Cardiac Arrest and the role of Targeted Temperature Management

Introduction: While Acute Kidney Injury (AKI) is a common complication of cardiac arrest (CA), the incidence of AKI and Chronic Kidney Disease (CKD) following resuscitation are not well studied. Further, the association of Targeted Temperature Management (TTM) with AKI and CKD incidence has not been extensively studied. Aim: We compared the incidence of post-arrest AKI and CKD among patients who received TTM and those who did not receive TTM. Methods: In this retrospective cohort study, we studied adult patients following resuscitation from out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). Serum creatinine (Cr) data for post-arrest patients were extracted from the electronic medical record. Baseline serum Cr was defined as the most recent pre-arrest Cr value or the lowest Cr value within 6 hrs of arrest. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, AKI was defined as an increase in Cr by &gt; 0.3 mg/dL within 48 hrs or an increase in serum Cr by 1.5x the baseline value within a one-week period. CKD was defined as a GFR of &lt; 60 mL/min per 1.73 m 2 3 months post-arrest. Results: From 1/2005 to 12/2017, 1099 patients had serial post-arrest creatinine values available. Median age at arrest was 63 (IQR 25), 58% were male, survival to discharge was 20%, with a 17 % favorable CPC score of 1 or 2. Of these, 240 patients had documented TTM status (89 received TTM and 151 did not). Of the patients who received TTM, 31% developed AKI compared to 40 % who did not receive TTM (P=NS). The incidence of CKD was 56% in the TTM group and 45% in the non-TTM group. McNemar’s test for CKD at baseline and at 3 months post-arrest showed a significant increase in the incidence of CKD post arrest (45% vs. 49%, p = 0.031). Conclusions: Post cardiac arrest, AKI and CKD are common complications. The use of TTM was not associated with the incidence of AKI or CKD. Further research is needed to study factors that affect AKI and CKD in CA.