The association of targeted temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the Target Temperature Management trial
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We hypothesized that a targeted temperature of 33 °C as compared to that of 36 °C would increase survival and reduce the severity of circulatory shock in patients with shock on admission after out-of-hospital cardiac arrest (OHCA).
The recently published Target Temperature Management trial (TTM-trial) randomized 939 OHCA patients with no difference in outcome between groups and no difference in mortality at the end of the trial in a predefined subgroup of patients with shock at admission. Shock was defined as a systolic blood pressure of <90 mm Hg for >30 min or the need of supportive measures to maintain a blood pressure ≥90 mmHg and/or clinical signs of end-organ hypoperfusion. In this post hoc analysis reported here, we further analyzed the 139 patients with shock at admission; all had been randomized to receive intervention at 33 °C (TTM33; n = 71) or 36 °C (TTM36; n = 68). Primary outcome was 180-day mortality. Secondary outcomes were intensive care unit (ICU) and 30-day mortality, severity of circulatory shock assessed by mean arterial pressure, serum lactate, fluid balance and the extended Sequential Organ Failure assessment (SOFA) score.
There was no significance difference between targeted temperature management at 33 °C or 36 °C on 180-day mortality [log-rank test, p = 0.17, hazard ratio 1.33, 95 % confidence interval (CI) 0.88–1.98] or ICU mortality (61 vs. 44 %, p = 0.06; relative risk 1.37, 95 % CI 0.99–1.91). Serum lactate and the extended cardiovascular SOFA score were higher in the TTM33 group (p < 0.01).
We found no benefit in survival or severity of circulatory shock with targeted temperature management at 33 °C as compared to 36 °C in patients with shock on admission after OHCA.
KeywordsCardiac arrest Cardiogenic shock Circulatory failure Post-cardiac arrest syndrome Outcome Hypothermia
Support was provided by independent research grants from the Swedish Heart–Lung Foundation, Arbetsmarknadens Försäkringsaktiebolag Insurance foundation, Swedish Research Council, Region Skåne (Sweden), National Health Service (Sweden), Thelma Zoegas Foundation, Krapperup Foundation, Thure Carlsson Foundation, Hans-Gabriel and Alice Trolle-Wachtmeister Foundation for Medical Research, Skåne University Hospital, TrygFonden (Denmark), European Clinical Research Infrastructures Network and European Union Interreg programme IV A.
Conflicts of interest
Hans Friberg and Tommaso Pellis have received lecture fees from Bard Medical. Matt P. Wise has consulted for Bard and Merck (Advisory Boards), is employed by NISCHR AHSC (research fellowship 0.4 WTE) and has received royalties from Wiley Publishing (book chapters), a fee for lecturing at an educational meeting from Fisher & Paykel, financial support for travel from ISICEM, Eli Lilly, British Thoracic Society and the Intensive Care Society, a loan of EIT equipment for research from Care Fusion and a gift of oral care products for research from Sage Products.
- 1.Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T (2013) The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 84:337–342Google Scholar
- 3.Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Aneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Kober L, Langorgen J, Lilja G, Moller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H, Investigators TTMT (2013) Targeted temperature management at 33 °C vs 36 °C after cardiac arrest. N Engl J Med 369:2197–2206PubMedCrossRefGoogle Scholar
- 6.Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bottiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV (2008) Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 79:350–379PubMedCrossRefGoogle Scholar
- 7.Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, Buller CE, Jacobs AK, Slater JN, Col J, McKinlay SM, LeJemtel TH (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 341:625–634PubMedCrossRefGoogle Scholar
- 8.Bougouin W, Lamhaut L, Marijon E, Jost D, Dumas F, Deye N, Beganton F, Empana JP, Chazelle E, Cariou A, Jouven X (2014) Characteristics and prognosis of sudden cardiac death in Greater Paris : population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC). Intensive Care Med. doi: 10.1007/s00134-014-3252-5
- 21.Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 26:1793–1800PubMedCrossRefGoogle Scholar
- 25.Jacobshagen C, Pelster T, Pax A, Horn W, Schmidt-Schweda S, Unsold BW, Seidler T, Wagner S, Hasenfuss G, Maier LS (2010) Effects of mild hypothermia on hemodynamics in cardiac arrest survivors and isolated failing human myocardium. Clin Res Cardiol 99:267–276PubMedCentralPubMedCrossRefGoogle Scholar
- 28.Buijs EA, Verboom EM, Top AP, Andrinopoulou ER, Buysse CM, Ince C, Tibboel D (2014) Early microcirculatory impairment during therapeutic hypothermia is associated with poor outcome in post-cardiac arrest children: a prospective observational cohort study. Resuscitation 85:397–404PubMedCrossRefGoogle Scholar
- 32.Schortgen F, Clabault K, Katsahian S, Devaquet J, Mercat A, Deye N, Dellamonica J, Bouadma L, Cook F, Beji O, Brun-Buisson C, Lemaire F, Brochard L (2012) Fever control using external cooling in septic shock: a randomized controlled trial. Am J Respir Crit Care Med 185:1088–1095PubMedCrossRefGoogle Scholar