Abstract
Cardiac arrest is common and causes substantial morbidity and mortality. Despite advances in prevention and resuscitation, most patients remain unconscious and survival remains poor. Therapeutic hypothermia (32–34 °C) has emerged as a potent neuroprotective modality following resuscitation. In early clinical trials, application of therapeutic hypothermia improved survival in patients with ventricular fibrillation (VF), which led to the recommended use of therapeutic hypothermia for patients resuscitated from VF. However, two recent clinical trials have challenged some assumptions. First, the use of paramedic-initiated rapid infusion of cold crystalloids as a mean to achieve faster cooling rates after resuscitation in patients with and without VF arrest did not improve survival. Second, once patients were admitted to the hospital, targeting their temperature to 33 versus 36 °C for 36 h (in addition to active hyperthermia prevention) after out-of-hospital cardiac arrest did not to change clinical outcomes, suggesting that 36 °C may represent the target temperature instead of temperatures of less than 34 °C.
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References
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Zheng ZJ, Croft JB, Giles WH, et al. Sudden cardiac death in the United States, 1989 to 1998. Circulation. 2001;104:2158–63.
Chugh SS, Jui J, Gunson K, et al. Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. Community. J Am Coll Cardiol. 2004;44:1268–75.
Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28–292.
Fugate JE, Brinjikji W, Mandrekar JN, et al. Post-cardiac arrest mortality is declining: a study of the us national inpatient sample 2001 to 2009. Circulation. 2012;126:546–50.
Moore EM, Nichol AD, Bernard SA, et al. Therapeutic hypothermia: benefits, mechanisms and potential clinical applications in neurological, cardiac and kidney injury. Injury. 2011;42:843–54.
Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549–56.
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–63.
Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S768–86.
Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. JAMA J Am Med Assoc. 2014;311:45–52. A large randomized clinical trial of early pre-hospital cooling.
Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees c versus 36 degrees c after cardiac arrest. N Engl J Med. 2013;369:2197–206. The largest randomized trial of hospital initiated hypothermia.
Kuboyama K, Safar P, Radovsky A, et al. Delay in cooling negates the beneficial effect of mild resuscitative cerebral hypothermia after cardiac arrest in dogs: a prospective, randomized study. Crit Care Med. 1993;21:1348–58.
Bernard SA, Smith K, Cameron P, et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation. 2010;122:737–42.
Abella BS, Zhao D, Alvarado J, et al. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation. 2004;109:2786–91.
Che D, Li L, Kopil CM, et al. Impact of therapeutic hypothermia onset and duration on survival, neurologic function, and neurodegeneration after cardiac arrest. Crit Care Med. 2011;39:1423–30.
Yannopoulos D, Zviman M, Castro V, et al. Intra-cardiopulmonary resuscitation hypothermia with and without volume loading in an ischemic model of cardiac arrest. Circulation. 2009;120:1426–35.
Castren M, Nordberg P, Svensson L, et al. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (prince: pre-ROSC intranasal cooling effectiveness). Circulation. 2010;122:729–36.
Yu T, Barbut D, Ristagno G, et al. Survival and neurological outcomes after nasopharyngeal cooling or peripheral vein cold saline infusion initiated during cardiopulmonary resuscitation in a porcine model of prolonged cardiac arrest. Crit Care Med. 2010;38:916–21.
Wolfson MR, Malone DJ, Wu J, et al. Intranasal perfluorochemical spray for preferential brain cooling in sheep. Neurocrit Care. 2008;8:437–47.
Zeiner A, Holzer M, Sterz F, et al. Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med. 2001;161:2007–12.
Bro-Jeppesen J, Hassager C, Wanscher M, et al. Post-hypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest. Resuscitation. 2013;84:1734–40.
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Paco E. Bravo and Francis Kim declare that they have no conflict of interest.
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This article is part of the Topical Collection on Clinical Trials and Their Interpretations
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Bravo, P.E., Kim, F. Enhancing Approaches to Therapeutic Hypothermia in Patients with Sudden Circulatory Arrest. Curr Atheroscler Rep 16, 451 (2014). https://doi.org/10.1007/s11883-014-0451-z
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DOI: https://doi.org/10.1007/s11883-014-0451-z