Clinical paperPyrexia and neurologic outcomes after therapeutic hypothermia for cardiac arrest☆
Introduction
Therapeutic hypothermia improves both survival and neurologic outcome when initiated after resuscitation from cardiac arrest.1, 2, 3, 4 Contemporary protocols for therapeutic hypothermia, known more broadly as therapeutic temperature management (TTM), consist of a cooling phase, a maintenance phase in which temperature is held at 32–34 °C, and a rewarming phase in which normothermia is restored and active temperature control is removed. Subsequent to rewarming, “rebound pyrexia” has been observed, with temperature elevations >38 °C within 24 h of the cessation of active temperature control. Pyrexia has been associated with worsened neurologic outcomes in other disease states such as subarachnoid hemorrhage and traumatic brain injury.5, 6 While investigations have evaluated temperature dynamics during induction and maintenance of post-arrest TTM,7, 8, 9 rebound pyrexia immediately following post-arrest TTM remains poorly characterized with regard to frequency as well as its association with clinical outcomes.
We sought to measure the incidence of rebound pyrexia in patients who received post-arrest TTM. We hypothesized that post-rewarming pyrexia was common and would be associated with worsened clinical outcomes at hospital discharge following cardiac arrest.
Section snippets
Methods
A retrospective analysis was performed using data from the Penn Alliance for Therapeutic Hypothermia (PATH) registry. PATH was established in 2010 as a multicenter U.S.-based registry hosted by the University of Pennsylvania Health System, to serve as a clinical data repository for cardiac arrest and post-arrest care. All PATH member institutions received Institutional Review Board approval or waiver to participate in studies of the pooled registry data. The current investigation received
Results
A total of 2023 adult cardiac arrests from 11 institutions were evaluated for inclusion in the current analysis, occurring between 5/2005 and 10/2011. Of those, 981/2023 (49%) cases exhibited return of spontaneous circulation (ROSC) and 236/981 (24%) were treated with TTM following resuscitation. The 236 TTM-treated patients served as the primary cohort for this investigation.
Demographic and event data from the TTM-treated cohort are shown in Table 2. The mean age was 58.1 ± 15.7 y; 106/236 (45%)
Discussion
In this multicenter analysis of resuscitated cardiac arrest patients treated with TTM, pyrexia within 24 h after rewarming was frequent (occurring in 41% of patients) and pronounced (pyrexic patients had a median temperature maximum of 38.7 °C). Patients with any magnitude of pyrexia had similar survival to discharge and neurologic status at discharge to patients without temperature elevations. However, pyrexia with temperature greater than the median temperature of 38.7 °C was associated with
Conclusions
Pyrexia, defined as a temperature ≥38 °C within 24 h following rewarming from post-arrest TTM, occurred in 41% of patients in our multicenter cohort. The subset of patients with maximum temperatures above the median pyrexia temperature had worse neurologic status at discharge than patients with milder or no pyrexia. The addition of a period of “therapeutic normothermia” subsequent to TTM rewarming should be evaluated as a component of post-arrest critical care; the duration of this period of time
Conflict of interest statement
Ms. Leary has received consulting fees from Stryker Medical; Dr. Abella has received honoraria from Medivance Corporation, Stryker Medical and Philips Healthcare and research support from Philips Healthcare; Dr. Gaieski has received honoraria and research support from Stryker Medical.
Acknowledgements
We would like to thank the participating PATH hospitals for their continued efforts to improve cardiac arrest care for their patients. We would also like to thank Anna Tommasini and Marisa Cinousis for their help with data processing.
References (25)
- et al.
Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest
Resuscitation
(2009) - et al.
Therapeutic hypothermia after cardiac arrest: a retrospective comparison of surface and endovascular cooling techniques
Resuscitation
(2010) - et al.
Body temperature regulation and outcome after cardiac arrest and therapeutic hypothermia
Resuscitation
(2012) - et al.
The influence of rewarming after therapeutic hypothermia on outcome after cardiac arrest
Resuscitation
(2012) - et al.
Reporting of data from out-of-hospital cardiac arrest has to involve emergency medical dispatching—taking the recommendations on reporting OHCA the Utstein style a step further
Resuscitation
(2011) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest
N Engl J Med
(2002)- et al.
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med
(2002) - et al.
Therapeutic hypothermia after cardiac arrest in clinical practice: review and compilation of recent experiences
Crit Care Med
(2009) - et al.
Fever management in SAH
Neurocrit Care
(2011) - et al.
Chinese Head Trauma Data Bank: effect of hyperthermia on the outcome of acute head trauma patients
J Neurotrauma
(2012)
Therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets
Crit Care Med
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2020, NeurotherapeuticsPost Cardiac Arrest Care in the Cardiac Intensive Care Unit
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.11.003.
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On behalf of the PATH investigators (see Appendix A).