1 / 30

Therapeutic Hypothermia in Out of Hospital Cardiac Arrest towards

Therapeutic Hypothermia in Out of Hospital Cardiac Arrest towards. ?. Cara Jager Aios Spoed Eisende Geneeskunde AMC Regionale Refereeravond Juli 2013. Therapeutic Hypothermia in OHCA: Background. Europe: ± 10 - 20% survives OHCA Mortality and morbidity largely due to anoxic brain injury

luella
Download Presentation

Therapeutic Hypothermia in Out of Hospital Cardiac Arrest towards

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Therapeutic Hypothermiain Out of Hospital Cardiac Arresttowards ? Cara Jager Aios Spoed Eisende Geneeskunde AMC Regionale Refereeravond Juli 2013

  2. Therapeutic Hypothermia in OHCA: Background • Europe: ± 10 - 20% survives OHCA • Mortality and morbidity largely due to anoxic brain injury • 7-30% good neurological outcome • Therapeutic hypothermia (TH)/ Mild Induced Hypothermia (MIH) recommended current guidelines • Bernard et al. N Engl J Med 2002 • HACA study group. N Engl J Med 2002

  3. Therapeutic HypothermiaCurrent Practice • Which population? • Post cardiac arrest/ ROSC • No recent trauma • - GCS ≤ 8 When? - Post cardiac arrest • Where? • Inhospital • How? • External cooling techniques • Internal cooling techniques

  4. Therapeutic Hypothermia:Current Practice the Netherlands Induction • Sedation • Cold fluids 4°C • Cool Mattress Maintenance • Target temperature 32°- 34° within 4 hours • 24 hrs Rewarming • Slow, 0.25- 0.5 °C/h within 8 hours • Stop sedation at 36°C • Awake/ Postanoxic coma?

  5. Therapeutic HypothermiaReally Effective? PRO Nolan J and Soar J. BMJ 2011 CON Walden AP, Nielsen et al. BMJ 2011

  6. ProNeurological Outcome NNT = 5 Arrich et al. Cochrane 2010

  7. Therapeutic HypothermiaPRO • Evidence good enough to support mild induced hypothermia in OHCA • Patients with VF • In other circumstances evidence weaker (neurological outcome generally worse) • Package of care in resuscitation protocol • By no means perfect trials

  8. Therapeutic HypothermiaCON • Bernard 2002: • Quasi randomization with odd and even dates • Unplanned adaptive design: • nonscheduled interim analysis after inclusion of 80% of the patients (no adjustment of P-value)

  9. ConNeurological Outcome Nielsen et al. Int J Cardiology 2011

  10. Con • Majority of the trials compared therapeutic hypothermia with no temperature control in the control groups • Control groups: majority not treated for fever, median temp: 37°C - 38°C • Intervention effect due to: • Increased temperature in control group? • Beneficial induced hypothermia? • Both? • Observational data poor outcome with higher temperatures: • OR 2.26 (1.24–4.12) for every degree higher than 37 °C • Clear association, how about causality? Nielsen et al. Int J Cardiology 2011

  11. Targeted Temperature Management = TTM trial Targeted Temperature Management = TTM trial Nielsen et al. Am Heart J 2012

  12. TTM-trial: protocol • International, multicenter RCT • Assessor blinded • Inclusion: ≥ 850 patients • Controlled hypothermia 33° versus controlled 36° • Standardized treatment decisions • Outcome: • All cause mortality • Poor neurological function • Adverse events • Presented at American Heart Association meeting November 2013 Dallas

  13. Therapeutic HypothermiaReally effective? • Current practice: ICU • Timing of Therapeutic hypothermia • Animal models: as early as possible • When?

  14. Therapeutic HypothermiaWhen? • Emergency Department? Egmond 2013

  15. Optimal timing of TH? Regression-analysis • For every 5 minute delay in initiating TH: increased chance of having a poor neurological outcome OR 1.06 (95% CI 1.02-1.10) • Retrospective observational study • Clear association, how about causality? Sendelbach et al. Resuscitation 2012

  16. Therapeutic HypothermiaWhen? • Pre-hospital setting?

  17. Therapeutic HypothermiaPre-Hospital Medline 1966 – 06-2013 induced hypothermia [MESH] hypothermia [MESH] hypothermia, induced [MESH] induced mild hypothermia [MESH] induced moderate hypothermia [MESH] cooling [T/A] therapeutic [T/A] AND hypothermia [T/A] therapeutic [T/A] AND cooling [T/A] 50952 prehospital [T/A] pre-hospital [T/A] paramedic*[T/A] 12942 intra-arrest [T/A] intra arrest [T/A] intraarrest [T/A] post-arrest [T/A] post arrest [T/A] postarrest [T/A] 13259 arrest [T/A] cardiac arrest [T/A] OHCA [T/A] out of hospital cardiac arrest [T/A] out-of-hospital cardiac arrest T/A] out of hospital cardiac arrest [MESH] 83480 AND AND 187 hits Limits English Total 173 hits 40 relevant: 8 RCT 8 Review Pre hospital/ Emergency Department: Post-arrest/ post-ROSC Intra-arrest

  18. Therapeutic HypothermiaPre- Hospital Diao et al. Resuscitation 2013

  19. RCT, n= 37 • Ice cold saline infusion versus normal treatment Bottom line: • Prehospital induction of mild hypothermia is feasible • Cooling rate 2°C/h (95% CI 1.5-2.7) • Not to the level of therapeutic hypothermia ActaAnaesthesiol Scand 2009

  20. Kim et al. Circulation 2007 • RCT, n= 125 • Ice cold saline infusion versus normal treatment Bottom line: • Significant lower temperature at hospital arrival with ice cold saline • volume dependent • Not associated with adverse events (i.e. pulmonary edema, rearrest) *P0.0001 by ANOVA

  21. Therapeutic HypothermiaPre- Hospital: Improving Outcome? Bernard et al. Circulation 2010 Bernard et al. Crit Care Med 2012

  22. 6730= Total cardiac arrests during trial period Prospective multicenter RCT Australia Oct 2005- Nov 2007 6436 = Adults ≥ 15y with cardiac arrest during trial period 4763= Cardiac arrest of presumed cardiac cause 2268= Resuscitation attempted by paramedics Bernard et al 2010 Bernard et al 2012 842= Initial rhythm ventricular fibrillation 1426= Initial rhythm asystole/ PEA 398= ROSC and transport to hospital 309= ROSC and transport to hospital 164= Eligible/ Not enrolled 146= Eligible/ Not enrolled 163= Eligible and enrolled 234= Eligible and enrolled 118= Paramedic cooling 100 ml/min cold saline up to 2l 116= Hospital cooling 82= Paramedic cooling 100 ml/min cold saline up to 2l 82= Hospital cooling 118= Assessed for 1° endpoint 116= Assessed for 1° endpoint 82= Assessed for 1° endpoint 81= Assessed for 1° endpoint

  23. PostarrestPrehospital Cooling:Improving Outcome? Bottom line: In pre-hospital cooled group • Significant decrease in temperature at hospital arrival • Less time to reach therapeutic hypothermia (<34°C) • No benefit cooling in the field in patients with OHCA • either VF or nonVF WHY? Bernard et al. 2010 and 2012

  24. Rewarming? • Cooling in field or ED same temperature 1h after arrival Bernard et al. 2010

  25. Therapeutic HypothermiaPrehospital setting • Feasible lowering temperatures • No outcome differences Diao et al. Resuscitation 2013

  26. TherapeuticHypothermia:Summary • Currentpractice • To believeornot to believe TowardsThe ColdChain • Prehospitalcooling: • Post-arrest, feasible • Intra-arrest, the future? • Packageof care?

  27. Intra-Arrest? Package of Care? BMC Emergency Medicine 2011 J Translational Medicine 2012

  28. Baseline Characteristics Bernard 2010 VF/ VT Bernard 2012 non- VF

  29. Baseline Characteristics Diao et al. Resuscitation 2013

More Related