Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units

doi:10.1016/j.resuscitation.2014.04.023

Resuscitation

Volume 85, Issue 8, August 2014, Pages 1012-1017

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Abstract

Introduction

Target temperature management (TTM) after cardiac arrest is recommended by international guidelines, which have been last updated in 2010. Here we investigate the status of implementation in a nationwide survey in Germany which took place in 2012.

Methods

We conducted a nationwide telephone survey including a total of 951 German intensive care units (ICUs). ICUs were identified by using the online registry for hospitals in Germany. A questionnaire was used for the interview about basic data of the intensive care unit and about details concerning use and implementation of TTM after cardiac arrest.

Results

The overall response rate was 91% (865/951). 86% (742/865) of ICUs used TTM after cardiac arrest and implementation peaked in 2010. 95% (702/736) of the ICUs using TTM perform treatment independently of the initial rhythm and 48% (355/738) apply TTM with the use of a feedback device for cooling and controlled re-warming. However, 22% (166/742) still use conventional methods like ice and cold infusion and only 61% (453/742) of the participants provided a written standard operating procedure (SOP).

Conclusion

With a delay of several years, TTM after cardiac arrest is now implemented in the majority of German ICUs. The moderate proportion of ICUs using SOPs for TTM and feedback-controlled cooling devices indicates the need of further improvement in post cardiac arrest care.

Introduction

In post-resuscitation care after cardiac arrest targeted temperature management (TTM) as a key treatment has been recommended since 2003 by international guidelines.¹ Initially only suggested in patients after out-of-hospital (OHCA) shockable cardiac arrest the indication has been broadened over the years with currently recommending a temperature management to almost all survivors after cardiac arrest that remain comatose after resuscitation within the last update of the guidelines in 2010 although the level of evidence is lower in non-shockable cardiac arrest patients.² Before the last guideline update several studies have investigated the adherence of German intensive care units to the guidelines and the rate of application has increased in Germany from 23% (2005) to 69% (2008/2009).3, 4 This is the first nationwide survey after the last update of the recommendation concerning targeted temperature management after cardiac arrest in 2010. The aim was to investigate whether there is a still increasing rate of application of TTM, especially after the guideline update in 2010 has markedly broadened the indication of TTM after cardiac arrest.

Section snippets

Material and methods

The novel German online registry for hospital was used for identification of intensive care units (Deutsches Krankenhausverzeichnis; DKV: http://www.deutsches-krankenhaus-verzeichnis.de/). Hospitals have been legally obligated to register since 2005 and the register is based on the hospitals’ annual structured quality report. In addition to the official report hospitals are allowed to provide further data about specific treatments. The online search was performed in August 2012 in three steps

Results

The overall response rate was 91% (865/951), of the initially 951 ICUs, 3% (25/951) could not be contacted via telephone despite at least five attempts and of the remaining 926 ICUs, a total of 7% (61/926) refused to participate in the survey (Fig. 1). Thus the results from 865 interviewed ICUs are presented in the style of the questionnaire used.

Discussion

This is the first nationwide survey in Germany on the use of targeted temperature management after cardiac arrest following the update of the ERC recommendations on post-arrest treatment in 2010. Our survey indicates a further increase of implementation along with an increase of ICUs providing internal standard operating procedures for TTM. The majority of ICU used TTM independently of initial rhythm and only a minority reported routine preclinical hypothermia induction.

In 2006 Sander et al.

Limitations

Several limitations of our survey have to be addressed. First the method of a telephone interview introduces bias as data were obtained mainly from attending physicians, which may have answered some of the questions incorrectly. The same caveat applies to previous studies using a written questionnaire sent to the head of the ICU department. While the written form may increase the number of correct responses, the lower response rate obtained by this method could introduce additional bias not

Conclusion

With a delay of several years, targeted temperature management after cardiac arrest is now implemented in the majority of German ICUs. The moderate proportion of ICUs using SOPs for TTM, feedback-controlled cooling devices and routine coronary angiography indicate potential areas of further improvement in post cardiac arrest care.

Conflict of interest

CS received from Zoll GmbH, C.R.BARD and Medivance Inc. reimbursements for traveling, congress fees, honorarium for lectures and material support for various research projects; from COVIDIEN financial and material support for a research project; from Philips GmbH traveling costs and honorarium for a lecture; and from EMCOOL and NONIN material support for research projects.

CL received travel expenses, congress fee and honorarium for one lecture from C.R.Bard.

None of these companies or any other

Acknowledgment

We would like to thank all participants of the survey and we appreciated very much the high interest of almost all interviewed participants toward the final results of this survey.

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Cited by (24)

Repolarization and ventricular arrhythmia during targeted temperature management post cardiac arrest
2021, Resuscitation
Citation Excerpt :
Targeted temperature management (TTM)5,6 is currently the only guideline supported modality for reduction of anoxic brain injury. While TTM has been widely implemented,7 complications including impaired coagulation, infections and arrhythmia are frequent, affecting >50% of patients5,6,8 with cardiac arrhythmia being the most frequent.9,10 Lowering of the core temperature affects many organ systems, and hypothermia can increase risk of ventricular arrhythmia.11
Targeted temperature management (TTM) following out-of-hospital cardiac arrest (OHCA) prolongs the QT-interval but our knowledge of different temperatures and risk of arrhythmia is incomplete.
To assess whether the QTc, QT-peak (QTp) and T-peak to T-end interval (TpTe) may be useful markers of ventricular arrhythmia in contemporary post cardiac arrest treatment.
An ECG-substudy of the TTM-trial (TTM at 33 °C vs. 36 °C) with serial ECGs from 680 (94%) patients. Bazett’s (B) and Fridericia’s (F) formula were used for heart rate correction of the QT, QTp and TpTe. Ventricular arrhythmia (VT/VF) were registered during the first three days of post cardiac arrest care.
The QT, QTc and QTp intervals were prolonged more at 33 °C compared to 36 °C and restored to similar and lower levels after rewarming. The TpTe-interval remained between 92–100 ms throughout TTM in both groups.
The QTc intervals were associated with ventricular arrhythmia, but not after adjustment for cardiac arrest characteristics. The QTp-interval was not associated with risk of ventricular arrhythmia. Heart rate corrected TpTe-intervals were associated with higher risk of arrhythmia (Odds ratio (OR): TpTe(B): 1.12 (1.02–1.23, p = 0.01 TpTe(F): 1.12 (1.02–1.23, p = 0.02) per 20 ms). Further a prolonged TpTe-interval ≥ 90 ms was consistently associated with higher risk (OR_adjusted: TpTe(B): 2.05 (1.25–3.37), p < 0.01, TpTe(F): 2.14 (1.32–3.49), p < 0.01).
TTM prolongs the QT-interval by prolongation of the QTp-interval without association to increased risk. The TpTe-interval is not significantly affected by core temperature, but heart rate corrected TpTe intervals are robustly associated with risk of ventricular arrhythmia.
The TTM-trial is registered and accessible at ClinicalTrials.gov (Identifier: NCT01020916).
The current temperature: A survey of post-resuscitation care across Australian and New Zealand intensive care units
2020, Resuscitation Plus
Citation Excerpt :
Our study also demonstrated other variations in TTM treatment and post-resuscitation care–including the duration of TTM, use of cooling devices, prognostication and use of specific a post-resuscitation care clinical guideline. Similar variations have been reported in other international ICU surveys.17,33 The variation seen in duration and cooling methods most likely reflects those used in clinical trials.
Targeted temperature management (TTM) in post-resuscitation care has changed dramatically over the last two decades. However, uptake across Australian and New Zealand (NZ) intensive care units (ICUs) is unclear. We aimed to describe post-resuscitation care in our region, with a focus on TTM, and to gain insights into clinician’s opinions about the level of evidence supporting TTM.
In December 2017, we sent an online survey to 163 ICU medical directors in Australia (n = 141) and NZ (n = 22).
Sixty-one ICU medical directors responded (50 from Australia and 11 from NZ). Two respondents were excluded from analysis as their Private ICUs did not admit post-arrest patients. The majority of remaining respondents stated their ICU followed a post-resuscitation care clinical guideline (n = 41/59, 70%). TTM was used in 57 (of 59, 97%) ICUs, of these only 64% had a specific TTM clinical guideline/policy and there was variation in the types of patients treated, temperatures targeted (range = 33–37.5 °C), methods for cooling and duration of cooling (range = 12–72 h). The majority of respondents stated that their ICU (n = 45/57, 88%) changed TTM practice following the TTM trial: with 28% targeting temperatures >36 °C, and 23 (of 46, 50%) respondents expressed concerns with current level of evidence for TTM. Only 38% of post-resuscitation guidelines included prognostication procedures, few ICUs reported the use of electrophysiological tests.
In Australian and New Zealand ICUs there is widespread variation in post-resuscitation care, including TTM practice and prognostication. There also seems to be concerns with current TTM evidence and recommendations.
Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial
2017, Resuscitation
Citation Excerpt :
The American Heart Association, International Liaison Committee on Resuscitation, and other international agencies now strongly recommend TTM for eligible patients following resuscitation from cardiac arrest [4,5]. Despite these recommendations, TTM is delivered inconsistently, incompletely, and often with delay [6–9]. Reasons cited to explain this incomplete adoption include lack of awareness of recommended practice, perceptions of poor prognosis, limited time and resources, and staffing shortages [10–14].
Targeted temperature management (TTM) improves survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA), but is delivered inconsistently and often with delay.
To determine if prehospital cooling by paramedics leads to higher rates of ‘successful TTM’, defined as achieving a target temperature of 32–34 °C within 6 h of hospital arrival.
Pragmatic RCT comparing prehospital cooling (surface ice packs, cold saline infusion, wristband reminders) initiated 5 min after return of spontaneous circulation (ROSC) versus usual resuscitation and transport. The primary outcome was rate of ‘successful TTM’; secondary outcomes were rates of applying TTM in hospital, survival with good neurological outcome, pulmonary edema in emergency department, and re-arrest during transport.
585 patients were randomized to receive prehospital cooling (n = 279) or control (n = 306). Prehospital cooling did not increase rates of ‘successful TTM’ (30% vs 25%; RR, 1.17; 95% confidence interval [CI] 0.91–1.52; p = 0.22), but increased rates of applying TTM in hospital (68% vs 56%; RR, 1.21; 95%CI 1.07–1.37; p = 0.003). Survival with good neurological outcome (29% vs 26%; RR, 1.13, 95%CI 0.87–1.47; p = 0.37) was similar. Prehospital cooling was not associated with re-arrest during transport (7.5% vs 8.2%; RR, 0.94; 95%CI 0.54–1.63; p = 0.83) but was associated with decreased incidence of pulmonary edema in emergency department (12% vs 18%; RR, 0.66; 95%CI 0.44–0.99; p = 0.04).
Prehospital cooling initiated 5 min after ROSC did not increase rates of achieving a target temperature of 32–34 °C within 6 h of hospital arrival but was safe and increased application of TTM in hospital.
Post-resuscitation care in large and small University and community hospitals in Italy
2017, Resuscitation
A survey on general and temperature management of post cardiac arrest patients in large teaching and university hospitals in 14 European countries—The SPAME trial results
2017, Resuscitation
Citation Excerpt :
In addition to TTM for the treatment of ischemic-hypoxic brain injury, structured post-arrest treatment bundles including hemodynamic – optimization, early percutaneous coronary interventions (whenever indicated), controlled oxygen and carbon dioxide levels during mechanical ventilation and tight glucose control provide a substantial reduction of secondary brain insults [6,7] and were also included into recent recommendations to manage cardiac arrest (CA) survivors (4). However, the rate of implementation of these therapies widely varies between different European countries and TTM may still be an underused part of a standardized post-arrest clinical management [8–10]. Additionally, some centers stopped to use TTM after CA and moved to normothermia or fever control because of misinterpretation of the TTM study [11].
International guidelines recommend a bundle of care, including targeted temperature management (TTM), in post cardiac arrest survivors. Aside from a few small surveys in different European countries, adherence to the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) recommendations are unknown.
This international European telephone survey was conducted to provide an overview of current clinical practice of post cardiac arrest management with a main focus on TTM. We targeted large teaching and university hospitals within Europe as leading facilities and key opinion leaders in the field of post cardiac arrest care. Selected national principal investigators conducted the survey, which was based on a predefined questionnaire, between December 2014 and March 2015, before the publication of the ERC Guidelines 2015.
The return rate was 94% from 268 participating intensive care units (ICU). The majority had a predefined standard operating procedure (SOP) protocol for post cardiac arrest patients. Altogether, 68% of the ICUs provided TTM at a target temperature of 32–34 °C for 24 h, and 33% had changed the target temperature to 36 °C. The minority provided a written SOP for neurological prognostication, which was generally initiated 72 h after return of spontaneous circulation (ROSC). Electroencephalography and somatosensory evoked potentials were used by most ICUs for early prognostication. Treating more than fifty patients a year was significantly associated with providing written SOPs for TTM and prognostication (p < 0.01), as well as the use of a computer feedback device (p = 0.03) for TTM.
This international European telephone survey revealed a high rate of implementation of TTM in post cardiac arrest patients in university and teaching hospitals. Most participants also provided a SOP, but only a minority had a SOP for neurological prognostication.
Current practice of target temperature management post-cardiac arrest in the Netherlands, a post-TTM trial survey
2015, Resuscitation

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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.2014.04.023.

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Clinical paperUse of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units☆

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion

Limitations

Conclusion

Conflict of interest

Acknowledgment

Resuscitation

Resuscitation

Resuscitation

J Pediatr

Crit Care Clin

Resuscitation

Resuscitation

Resuscitation

Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Resuscitation

Clinical paper
Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units☆