Hypothermic versus Normothermic Temperature Control after Cardiac Arrest

Holgersson, Johan; Meyer, Mechthild; Dankiewicz, Josef; Lilja, Gisela; Ullén, Susann; Hassager, Christian; Cronberg, Tobias; Wise, Matt P.; Bělohlávek, Jan; Hovdenes, Jan; Pelosi, Paolo; Erlinge, David; Schrag, Claudia; Šmíd, Ondřej; Brunetti, Iole; Rylander, Christian; Young, Paul; Saxena, Manoj; Åneman, Anders; Cariou, Alain; Callaway, Clifton; Eastwood, Glenn M; Hænggi, Matthias; Joannidis, Michael; Kirkegaard, Hans; Leithner, Christoph; Levin, Helena; Nichol, Alistair; Morgan, Matt; Nordberg, Per; Oddo, Mauro; Storm, Christian; Taccone, Fabio Silvio; Thomas, Matthew; Bro-Jeppesen, John; Horn, Janneke; Kjærgaard, Jesper; Kuiper, Michael; Pellis, Tommaso; Stammet, Pascal; Wanscher, Michael; Friberg, Hans; Nielsen, Niklas; Jakobsen, Janus Christian

doi:10.1056/evidoa2200137

Cited by 28 publications

(15 citation statements)

References 40 publications

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“…1 The two randomised TTM trials ('TTM trial' and 'TTM2 trial') studied hypothermia at 33 versus 36 C, and 33 C versus normothermia with early treatment of fever in out-of-hospital cardiac arrest (OHCA). 2,3 Both trials found similar survival and neurological outcomes in the respective temperature groups, also when pooled in a meta-analysis defining normothermia as 36.0-37.7 C. 4 In contrast, the HYPERION trial, including both OHCA and in-hospital cardiac arrest found a better neurological outcome in patients treated with 33 as compared to 37 C. 5 The updated European Resuscitation Council and European Society of Intensive Care Medicine (ESICM) guidelines recommend to actively prevent fever (core temperature >37.7 C) targeting 37.5 C but state that evidence for targets between 32 and 36 C are insufficient for recommendation for or against. 6 However, given the equipoise between hypothermia and normothermia in OHCA and the wide range of target temperatures having been recommended before the last guideline update, current practice may vary.…”

Section: Introductionmentioning

confidence: 88%

“…Normothermia was defined as 36.0-37.7 C in line with a recent meta-analysis. 4 Data on number of admitted patients in 2022 were collected from the open data portal of the Swedish Intensive Care Registry. 10 A structured telephone survey was conducted in all (= 53) Swedish Levels 2 and 3 ICUs during April and May 2022.…”

Section: Methodsmentioning

confidence: 99%

“…Respondents were invited to participate in the survey in their professional capacity for their respective site. Normothermia was defined as 36.0–37.7°C in line with a recent meta‐analysis 4 . Data on number of admitted patients in 2022 were collected from the open data portal of the Swedish Intensive Care Registry 10…”

Section: Methodsmentioning

confidence: 99%

“…The two randomised TTM trials (‘TTM trial’ and ‘TTM2 trial’) studied hypothermia at 33 versus 36°C, and 33°C versus normothermia with early treatment of fever in out‐of‐hospital cardiac arrest (OHCA) 2,3 . Both trials found similar survival and neurological outcomes in the respective temperature groups, also when pooled in a meta‐analysis defining normothermia as 36.0–37.7°C 4 . In contrast, the HYPERION trial, including both OHCA and in‐hospital cardiac arrest found a better neurological outcome in patients treated with 33 as compared to 37°C 5 .…”

Section: Introductionmentioning

confidence: 99%

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Post‐cardiac arrest intensive care in Sweden: A survey of current clinical practice

Järpestam,

Martinell,

Rylander

et al. 2023

Acta Anaesthesiol Scand

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BackgroundEuropean guidelines recommend targeted temperature management (TTM) in post‐cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known.AimThe aim of this study was to investigate current practice in post‐resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs).MethodsA structured survey was conducted by telephone or e‐mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023.ResultsFive units were not providing post‐cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36–37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72–96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available.ConclusionSwedish ICUs use normothermia including early treatment of fever in post‐resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.

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Section: Introductionmentioning

confidence: 88%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Post‐cardiac arrest intensive care in Sweden: A survey of current clinical practice

Järpestam,

Martinell,

Rylander

et al. 2023

Acta Anaesthesiol Scand

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“… 50 One recent meta-analysis comparing hypothermic to normothermic management did not find a difference in 6-month mortality or functional outcomes using the Rankin score for both older and younger age groups. 69 While older age is associated with decreased survival after cardiac arrest, there is limited evidence on functional and neurologic outcomes specific to geriatric patients. This lack of data may impact code status discussions with patients and their family members and should be a goal of future studies.…”

Section: System-specific Considerations In Older Adultsmentioning

confidence: 99%

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

Brunker

Boncyk

Rengel

et al. 2023

CIA

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There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

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Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm

Taccone,

Dankiewicz,

Cariou

et al. 2024

JAMA Neurol

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ImportanceInternational guidelines recommend body temperature control below 37.8 °C in unconscious patients with out-of-hospital cardiac arrest (OHCA); however, a target temperature of 33 °C might lead to better outcomes when the initial rhythm is nonshockable.ObjectiveTo assess whether hypothermia at 33 °C increases survival and improves function when compared with controlled normothermia in unconscious adults resuscitated from OHCA with initial nonshockable rhythm.Data SourcesIndividual patient data meta-analysis of 2 multicenter, randomized clinical trials (Targeted Normothermia after Out-of-Hospital Cardiac Arrest [TTM2; NCT02908308] and HYPERION [NCT01994772]) with blinded outcome assessors. Unconscious patients with OHCA and an initial nonshockable rhythm were eligible for the final analysis.Study SelectionThe study cohorts had similar inclusion and exclusion criteria. Patients were randomized to hypothermia (target temperature 33 °C) or normothermia (target temperature 36.5 to 37.7 °C), according to different study protocols, for at least 24 hours. Additional analyses of mortality and unfavorable functional outcome were performed according to age, sex, initial rhythm, presence or absence of shock on admission, time to return of spontaneous circulation, lactate levels on admission, and the cardiac arrest hospital prognosis score.Data Extraction and SynthesisOnly patients who experienced OHCA and had a nonshockable rhythm with all causes of cardiac arrest were included. Variables from the 2 studies were available from the original data sets and pooled into a unique database and analyzed. Clinical outcomes were harmonized into a single file, which was checked for accuracy of numbers, distributions, and categories. The last day of follow-up from arrest was recorded for each patient. Adjustment for primary outcome and functional outcome was performed using age, gender, time to return of spontaneous circulation, and bystander cardiopulmonary resuscitation.Main Outcomes and MeasuresThe primary outcome was mortality at 3 months; secondary outcomes included unfavorable functional outcome at 3 to 6 months, defined as a Cerebral Performance Category score of 3 to 5.ResultsA total of 912 patients were included, 490 from the TTM2 trial and 422 from the HYPERION trial. Of those, 442 had been assigned to hypothermia (48.4%; mean age, 65.5 years; 287 males [64.9%]) and 470 to normothermia (51.6%; mean age, 65.6 years; 327 males [69.6%]); 571 patients had a first monitored rhythm of asystole (62.6%) and 503 a presumed noncardiac cause of arrest (55.2%). At 3 months, 354 of 442 patients in the hypothermia group (80.1%) and 386 of 470 patients in the normothermia group (82.1%) had died (relative risk [RR] with hypothermia, 1.04; 95% CI, 0.89-1.20; P = .63). On the last day of follow-up, 386 of 429 in the hypothermia group (90.0%) and 413 of 463 in the normothermia group (89.2%) had an unfavorable functional outcome (RR with hypothermia, 0.99; 95% CI, 0.87-1.15; P = .97). The association of hypothermia with death and functional outcome was consistent across the prespecified subgroups.Conclusions and RelevanceIn this individual patient data meta-analysis, including unconscious survivors from OHCA with an initial nonshockable rhythm, hypothermia at 33 °C did not significantly improve survival or functional outcome.

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Hypothermic versus Normothermic Temperature Control after Cardiac Arrest

Cited by 28 publications

References 40 publications

Post‐cardiac arrest intensive care in Sweden: A survey of current clinical practice

Post‐cardiac arrest intensive care in Sweden: A survey of current clinical practice

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

Hypothermia vs Normothermia in Patients With Cardiac Arrest and Nonshockable Rhythm

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