Coronary artery disease
Usefulness of Mild Therapeutic Hypothermia for Hospitalized Comatose Patients Having Out-of-Hospital Cardiac Arrest

https://doi.org/10.1016/j.amjcard.2011.03.021Get rights and content

Mild therapeutic hypothermia has proved beneficial after out-of-hospital cardiac arrest in the adult population, when the initial rhythm is ventricular fibrillation (VF). In this study, data from 110 consecutive patients with out-of-hospital cardiac arrest due to VF (n = 86) or to non-VF rhythm (n = 24), admitted to an intensive cardiac care unit with restoration of spontaneous circulation and who remained unconscious on admission, were analyzed. Patients were cooled using an external cooling system. Of the patients with VF, 66% had favorable outcomes (Glasgow-Pittsburgh Cerebral Performance Category 1 or 2), and 30% died. Of the patients with non-VF, 8% had favorable outcomes (p <0.001 vs VF), and 63% died (p = 0.004 vs VF). In patients with VF, those with poor outcomes were older than those with favorable outcomes (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.03 to 2.7, p = 0.001) and had previous ejection fractions <35% (OR 7.72, 95% CI 1.8 to 33, p = 0.002). Outcomes were also worse when patients presented to the emergency room with seizures (OR 20.96, 95% CI 2.48 to 177.42, p = 0.003) or hemodynamic instability (OR 14.4, 95% CI 3.47 to 60, p <0.0001). In the non-VF group, the 2 patients with good outcomes were younger than those with unfavorable outcomes (39 ± 16 vs 65 ± 12 years, respectively, p = 0.04), with good left ventricular function on presentation (100% vs 4.5%, p = 0.0001) and with short asystole and/or short time from collapse to restoration of spontaneous circulation. In conclusion, mild therapeutic hypothermia in the adult population is more effective in patients with VF compared to those with non-VF. Good prognostic factors for patients with non-VF could be young age, good left ventricular function, and short anoxic time.

Section snippets

Methods

From February 2002 to May 2009, 110 resuscitated comatose patients admitted to our intensive cardiac care unit after cardiac arrest (presumed to be of cardiac origin) were treated with MTH. Of these patients, the first rhythm recorded was VF in 86, asystole in 18, and PEA in 6. Exclusion criteria for MTH were pregnancy, terminal illness, cardiogenic shock, and known primary coagulopathy. The families of all 110 patients were informed about MTH, and 3 physicians gave signed approval for the

Results

From February 2002 to May 2009, data from a total of 110 consecutive patients treated with MTH were analyzed. Cardiac arrest was due to VF in 86 patients (78%) and to non-VF initial rhythms in 24 patients (22%). Baseline clinical and physiologic characteristics were comparable between the VF and non-VF groups (Table 1). Treatment was discontinued prematurely in 5 patients because of hemodynamic instability in 3 and death during cooling in 2. Goal temperature was achieved in 4 of them. All these

Discussion

In this study, we prospectively collected data from consecutive adult patients treated with MTH after CPR to assess the efficacy of MTH in patients after OHCA due to VF rhythm, to compare them to patients with non-VF and to evaluate prognostic factors of clinical outcomes. In the present study, despite a similar cooling protocol, patients with VF had substantially better outcomes compared to those with asystole or PEA.

In the VF group, younger age, lack of co-morbidities, and better baseline

References (22)

  • S. Hachimi-Idrissi et al.

    Mild hypothermia induced by a helmet device: a clinical feasibility study

    Resuscitation

    (2001)
  • J.P. Nolan et al.

    European Resuscitation Council guidelines for resuscitation 2010Section 1: executive summary

    Resuscitation

    (2010)
  • S. Bernard et al.

    Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report

    Resuscitation

    (2003)
  • A. Laish-Farkash et al.

    Therapeutic hypothermia for comatose survivors after cardia arrest

    IMAJ

    (2007)
  • M. Oddo et al.

    From evidence to clinical practice: effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest

    Crit Care Med

    (2006)
  • S. Wolfrum et al.

    Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention

    Crit Care Med

    (2008)
  • E. Sagalyn et al.

    Therapeutic hypothermia after cardiac arrest in clinical practice: review and compilation of recent experiences

    Crit Care Med

    (2009)
  • J.P. Nolan et al.

    Therapeutic hypothermia after cardiac arrestAn advisatory statement by the advanced life support task force of the International Liaison Committee on Resuscitation (ILCOR)

    Circulation

    (2003)
  • F. Kim et al.

    Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4°C normal saline

    Circulation

    (2007)
  • 2005 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendationsPart 4: advanced life support

    Resuscitation

    (2005)
  • L.J. Morrison et al.

    Part 8: advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations

    Circulation

    (2010)
  • Cited by (14)

    • Neurology of cardiopulmonary resuscitation

      2017, Handbook of Clinical Neurology
      Citation Excerpt :

      It is interesting to note that animal data indicate that initiating hypothermia after 12 hours has no benefit (Kuboyama et al., 1993). There are a multitude of commercially available devices, ranging from surface-cooling systems that include headgear (Hachimi-Idrissi et al., 2001; Storm et al., 2008), pads for the torso and extremities (Haugk et al., 2007; Heard et al., 2010), garments (Laish-Farkash et al., 2011), mattresses (Hypothermia after Cardiac Arrest Study Group, 2002) and nasal (Castrén et al., 2010) cooling systems, to invasive cooling via endovascular catheters (Flemming et al., 2006; Arrich and European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group, 2007; Pichon et al., 2007) and automated peritoneal lavage systems (de Waard et al., 2013; Polderman et al., 2015), to simpler methods such as applying ice packs and administering chilled intravenous fluids. Experiments on local brain cooling with intracranial cooling devices are still in the animal experiment stage, but appear to show some promise (Moomiaie et al., 2012).

    • Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient

      2015, Journal of the American College of Cardiology
      Citation Excerpt :

      There are now a total of 28 cohort studies of post-arrest STEMI patients who were comatose upon hospital arrival and therefore received TTM and coronary angiography. A summary of these data shows a survival to hospital discharge rate of 60%, with 86% of such survivors being neurologically intact (3,10–12,14,17,22,27,28,30–37) (Table 1). The International Liaison Committee on Resuscitation included the following statement in their 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations, “Therapeutic hypothermia is recommended in combination with primary PCI, and should be started as early as possible, preferably before initiation of PCI” (38,39), and the AHA 2010 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care states, “angiography and/or PCI need not preclude or delay other therapeutic strategies including therapeutic hypothermia” (39).

    • Effects of in-hospital low targeted temperature after out of hospital cardiac arrest: A systematic review with meta-analysis of randomized clinical trials

      2015, Resuscitation
      Citation Excerpt :

      Six references fulfilled our search criteria.7,16,17 Thirty references, including 3 RCTs evaluating the role of pre-hospital hypothermia, were excluded.18–42,3,43 Fig. 1 shows the study selection process.

    • Diagnosis of reversible causes of coma

      2014, The Lancet
      Citation Excerpt :

      A history of seizures or a seizure at onset, known psychiatric disease, vascular risk factors, and anticoagulant use all suggest other possible diagnoses. Knowledge that the coma was caused by a cardiac arrest has immediate therapeutic implications given the benefits of therapeutic hypothermia.15,16 The presence or absence of trauma must also be established.

    • Optimal treatment of patients surviving out-of-hospital cardiac arrest

      2012, JACC: Cardiovascular Interventions
      Citation Excerpt :

      Of interest, a majority of their patients were transferred from outlying hospitals. Finally, researchers from Israel found in 110 consecutive unconscious patients who were resuscitated from cardiac arrest and then treated with hypothermia and emergent coronary angiography an overall survival rate of 63%, with 86% of survivors having favorable neurological recovery (50). The 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment recommendations state: “Therapeutic hypothermia is recommended in combination with primary PCI, and should be started as early as possible, preferably before initiation of PCI” (36, p. S436).

    View all citing articles on Scopus
    View full text