Cold simple intravenous infusions preceding special endovascular cooling for faster induction of mild hypothermia after cardiac arrest—a feasibility study☆
Introduction
Prolonged global ischaemia during cardiac arrest and insufficient reperfusion during the immediate post-resuscitation period leads to severe hypoxic brain injury [1]. Several therapeutic interventions have been assessed for preventing or diminishing hypoxic brain damage after cardiac arrest. Despite promising results from experimental data most strategies failed to show beneficial effects in human or animal outcome studies [2], [3], [4], [5]. Therapeutic hypothermia has been used in cardiac surgery and neurosurgery and it is well known that patients suffering from hypothermic cardiac arrest have a better chance of recovering with good neurological outcome [6]. In the past, animal data has suggested that induction of therapeutic hypothermia after or in cardiac arrest could prevent hypoxic brain damage [7], [8]. In 2002, two randomized controlled trials presented good evidence for the efficacy of therapeutic mild hypothermia after cardiac arrest in humans [9], [10]. On the basis of these trials the International Liaison Committee on Resuscitation (ILCOR) now recommends that comatose adult survivors of out-of-hospital cardiac arrests whose first recorded rhythm was ventricular fibrillation should be cooled for 12–24 h and that this intervention might also be beneficial for in-hospital arrests or other rhythms [11].
Many different cooling techniques have been assessed for efficacy and safety, both in animals and humans [7], [12], [13], [14]. As there is evidence that the time until therapeutic hypothermia is reached has an important impact on outcome [15], [16], a simple cooling method that could be applied even out-of-hospital by paramedics or emergency physicians immediately after a return of spontaneous circulation potentially would be beneficial. So far, one study by Bernard et al. [17] showed that rapid infusions of large amounts (30 ml/kg) of cold fluids after cardiac arrest can be administered safely in patients without clinical signs of pulmonary oedema and that those infusions led to a significant decrease in patient core temperature. Extending this approach, our current study investigated the efficacy and safety of cold infusions for induction of hypothermia after cardiac arrest preceding further cooling and maintenance of hypothermia by specialised endovascular cooling.
Section snippets
Methods
The study was performed in an emergency department of a tertiary care hospital. Between 1 June 2003 and 15 April 2004 all patients after successful resuscitation from cardiac arrest were screened for eligibility. Data from all patients were collected according to the international “Utstein”—style criteria [18]. The procedures were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1964, as revised at the 52nd
Results
Over a period of 10.5 months, 26 patients (15%) were included out of 167 with cardiac arrest. Demographic and cardiac arrest data are given in Table 1. Causes of cardiac arrest other than cardiac were pulmonary (n = 1), near drowning (n = 1) and unknown in one patient.
Time from return of spontaneous circulation to admission was 38 (±23) min, time from return of spontaneous circulation to start of administration of cold infusions was 53 ± 29 min, infusions were started 14 ± 17 min after admission. In all
Discussion
The early induction of mild therapeutic hypothermia using rapid infusions of approximately 2 l of intravenous cold fluids at 4 °C immediately after admission to the emergency department preceding specialised endovascular cooling after cardiac arrest was feasible and safe. No harmful side effects were observed in patients given these amounts of cold fluids via peripheral intravenous lines shortly after restoration of spontaneous circulation.
Using a total amount of 24 ± 7 ml/kg body weight of Ringers’
Conclusions
Experimental data are indicating that therapeutic hypothermia can lead to better neuroprotection if applied soon after global ischemia. Therefore, earlier application of therapeutic hypothermia by simple methods, which could be used by medical professionals in the pre-hospital setting might offer a great potential for better neurological outcome. Techniques such as intravenous cold infusions preceding endovascular cooling could be used. To strengthen that assumption randomised controlled
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A Spanish and Portuguese translated version of the Abstract and Keywords of this article appears at doi: 10.1016/j.resuscitation.2004.09.002.