Clinical paperComparison of two sedation regimens during targeted temperature management after cardiac arrest☆
Introduction
Among comatose patients transported to hospital after cardiac arrest (CA), severe brain injury is the main cause of mortality [[1], [2], [3]]. Targeted temperature management (TTM) at either 33 or 36 °C during the first 24 h after return of spontaneous circulation (ROSC) is recommended in order to reduce anoxic-ischemic brain injury [[4], [5]]. Whatever the targeted level of temperature, these patients need to be adequately sedated during TTM in order to prevent shivering and to allow adequate ventilation [6]. Unfortunately, sedation may delay neurological recovery [7] after TTM and, therefore, the timing of neurological evaluation [[7], [8]]. Reducing the duration of uncertainty by refining the sedation regimen is crucial to avoid an inadequate prolongation of life-sustaining treatments in patients with an irreversible postanoxic brain injury.
Although guidelines recommend using short-acting-drugs for sedation in patients resuscitated from CA, current practices are heterogeneous and recent studies reported a prevalent or exclusive use of long-acting-drugs (mostly midazolam and fentanyl) [[6], [9], [10], [11], [12]]. These sedation regimens are associated with a delayed awakening in up to 30% of patients with good neurological recovery [7]. To date only one study compared short and long acting sedative [13]. However the small sample size did not allow multivariate adjustment. Considering the paucity of data, we decided to perform a comparison of two regimens of sedation and analgesia (long-acting-drugs, i.e., midazolam-fentanyl versus short-acting-drugs, i.e., propofol-remifentanil) in patients treated with TTM after resuscitation from CA. Our hypothesis was that a sedation regimen with short-acting-drugs would be associated with a reduction in the proportion of patients with delayed awakening, as compared with long-acting-drugs.
Section snippets
Population
We performed a study using prospectively collected data from the Parisian-Region-Out-of-Hospital-Cardiac-Arrest-Registry, previously published [[1], [7], [14]]. We included patients remaining comatose (Glasgow-Coma-Scale (GCS) ≤ 8) after CA and admitted to the intensive care unit (ICU) of Cochin Hospital (Paris, France). Exclusion criteria were: death from post-resuscitation shock within the first 48 h after ROSC and before a reliable neurological examination could be made; neurological cause
Characteristics and sedation
326 patients were included during P1 and 134 patients during P2 (Fig. 1). Baseline characteristics of included patients are described in Table 1. The rate of bystander CPR was higher during P2 (73% vs. 57% respectively; P = 0.001).
Patients included during P2 were older (64 years vs. 59 years, P = 0.004), and had a higher rate of post-resuscitation shock (60% vs. 45%, P = 0.005) before enrolment as compared with patients from P1. The severity of patients, as per CAHP score, did not significantly
Discussion
In this pragmatic study, sedation with propofol-remifentanil compared with midazolam-fentanyl was associated with a significantly lower rate of delayed awakening and a shorter duration of ventilation in patients sedated for TTM after cardiac arrest. The use of these short-acting-drugs was associated with a longer duration of catecholamine infusion, without an increase in the incidence of organ dysfunction. Finally, the use of short-acting-drugs allowed an earlier prognostication.
In the setting
Conclusion
In our study, the use of short-acting-drugs for sedation during TTM after cardiac arrest was associated with an earlier awakening, and a shorter duration of mechanical ventilation. This sedation regimen could allow an earlier prognostication after cardiac arrest, without increasing the risk complications or mortality.
Conflict of interest statement
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Acknowledgments
We thank Nancy Kentish-Barnes for her help in preparing the manuscript.
References (34)
- et al.
Assessment of outcome after severe brain damage
Lancet
(1975) - et al.
Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early?
Resuscitation
(2014) - et al.
The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest
Resuscitation
(2013) - et al.
Propofol vs midazolam for ICU sedation: a Canadian multicenter randomized trial
Chest
(2001) - et al.
Hypoxic hepatitis after out-of-hospital cardiac arrest: incidence, determinants and prognosis
Resuscitation
(2016) - et al.
Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort
Intensive Care Med
(2013) - et al.
Characteristics and prognosis of sudden cardiac death in Greater Paris: population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC)
Intensive Care Med
(2014) - et al.
Mode of death after admission to an intensive care unit following cardiac arrest
Intensive Care Med
(2004) - et al.
European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care
Intensive Care Med
(2015) - et al.
Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine
Intensive Care Med
(2014)
Anesthesia and analgesia protocol during therapeutic hypothermia after cardiac arrest: a systematic review
Anesth Analg
Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry
Intensive Care Med
Does this comatose survivor of cardiac arrest have a poor prognosis?
Intensive Care Med
Changes in cardiac arrest patients’ temperature management after the 2013 “TTM” trial: results from an international survey
Ann Intensive Care
The practice of therapeutic hypothermia after cardiac arrest in France: a national survey
PLoS One
Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature
Intensive Care Med
Endovascular versus external targeted temperature management for patients with out-of-hospital cardiac arrest: a randomized, controlled study
Circulation
Cited by (0)
- ☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at https://doi.org/10.1016/j.resuscitation.2018.03.025.
- 1
Both authors contributed equally.
- 2
Both last authors contributed equally.