Invasive versus non-invasive cooling after in- and out-of-hospital cardiac arrest: a randomized trial

Pittl, Undine; Schratter, Alexandra; Desch, Steffen; Diosteanu, Raluca; Lehmann, Denise; Demmin, Katharina; Hörig, Jacqueline; Schuler, Gerhard; Klemm, T; Mende, Meinhard; Thiele, Holger

doi:10.1007/s00392-013-0572-3

Cited by 76 publications

(69 citation statements)

References 34 publications

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“…8,[11][12][13][14]24,[33][34][35] In our study, we failed to demonstrate a clear clinical superiority of the endovascular cooling versus basic external cooling for the management of OHCA patients, despite important differences in the induction and maintenance phases of TTM. According to the literature, the level of evidence to assess the superiority of intravascular cooling on the prognosis after CA remains poor.…”

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confidence: 83%

“…13 Conversely, 3 other studies comparing endovascular with surface cooling methods found no significant difference in survival with good neurological outcome after a CA. 10,11 However, the time from CA to achieving TH was similar for both devices in 2 of these studies, 10,14 whereas the number of patients enrolled was rather limited, 11,14 leading to debatable conclusions about its potential clinical impact. Finally, most human studies found results similar to ours when several other devices were used to early achieve TH, especially with cold intravenous fluids.…”

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confidence: 97%

“…[5][6][7][10][11][12][13] The primary end point evaluated in the 2 small, randomized, controlled trials comparing advanced surface cooling pads and endovascular or basic surface cooling was the proportion of patients reaching the TT and the efficacy evaluated by the neuron-specific enolase levels but not survival. 14,15 Finally, multiple available cooling devices can be used alone or in combination. 5,6 To date, human studies have not demonstrated a clear clinical impact of early cooling associated with a strict maintenance phase of TH.…”

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confidence: 99%

“…5,6 To date, human studies have not demonstrated a clear clinical impact of early cooling associated with a strict maintenance phase of TH. 10,11,[14][15][16][17][18][19][20][21][22][23] Because endovascular cooling seems faster and more accurate than other available methods, 8,[11][12][13][14]24 the aim of the present study was to determine the clinical impact of advanced core endovascular cooling versus basic surface cooling after OHCA from a presumed cardiac cause in a multicenter, randomized, controlled trial.…”

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confidence: 99%

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Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest

et al. 2015

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Background— Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results— Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1–2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93–2.16; P =0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96–2.35; P =0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group ( P <0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group ( P =0.009). Conclusion— Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00392639.

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confidence: 83%

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confidence: 97%

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confidence: 99%

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Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest

et al. 2015

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“…Two Class III studies compared different invasive vs superficial cooling methods. 29,30 An additional Class III study 31 investigated the effect of a standardized treatment protocol. Because single Class III studies cannot drive recommendations, details of these studies are discussed only in the complete guideline.…”

Section: Conclusion and Recommendationsmentioning

confidence: 99%

Practice guideline summary: Reducing brain injury following cardiopulmonary resuscitation

et al. 2017

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Objective: To assess the evidence and make evidence-based recommendations for acute interventions to reduce brain injury in adult patients who are comatose after successful cardiopulmonary resuscitation.Methods: Published literature from 1966 to August 29, 2016, was reviewed with evidencebased classification of relevant articles. Results and recommendations:For patients who are comatose in whom the initial cardiac rhythm is either pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) after out-of-hospital cardiac arrest (OHCA), therapeutic hypothermia (TH; 32-348C for 24 hours) is highly likely to be effective in improving functional neurologic outcome and survival compared with non-TH and should be offered (Level A). For patients who are comatose in whom the initial cardiac rhythm is either VT/VF or asystole/pulseless electrical activity (PEA) after OHCA, targeted temperature management (368C for 24 hours, followed by 8 hours of rewarming to 378C, and temperature maintenance below 37.58C until 72 hours) is likely as effective as TH and is an acceptable alternative (Level B). For patients who are comatose with an initial rhythm of PEA/asystole, TH possibly improves survival and functional neurologic outcome at discharge vs standard care and may be offered (Level C). Prehospital cooling as an adjunct to TH is highly likely to be ineffective in further improving neurologic outcome and survival and should not be offered (Level A). Other pharmacologic and nonpharmacologic strategies (applied with or without concomitant TH) are also reviewed. Neurology ® 2017;88:2141-2149 GLOSSARY AAN 5 American Academy of Neurology; AE 5 adverse event; CI 5 confidence interval; CPC 5 Cerebral Performance Category; CPR 5 cardiopulmonary resuscitation; ECMO 5 extracorporeal membrane oxygenation; HF 5 hemofiltration; IHCA 5 in-hospital cardiac arrest; OHCA 5 out-of-hospital cardiac arrest; PEA 5 pulseless electrical activity; RD 5 risk difference; ROSC 5 return of spontaneous circulation; TH 5 therapeutic hypothermia; TTM 5 targeted temperature management; VT 5 ventricular tachycardia; VF 5 ventricular fibrillation.Outcomes for patients after nontraumatic cardiac arrest are dismal. Only 6%-9.6% of all patients with out-of-hospital cardiac arrest (OHCA) survive to hospital discharge, 1,2 and an estimated 22.3% of patients with in-hospital cardiac arrest (IHCA) survive to hospital discharge.3 Brain injury related to cardiac arrest is a major determinant of mortality and disability.

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In-Hospital Cardiac Arrest

Andersen

Holmberg

Berg

et al. 2019

JAMA

675

535

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IMPORTANCE In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest. OBSERVATIONS In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post–cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the Post–cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives. CONCLUSIONS AND RELEVANCE An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.

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Invasive versus non-invasive cooling after in- and out-of-hospital cardiac arrest: a randomized trial

Abstract: Invasive cooling has advantages with respect to temperature management over surface cooling; however, did not result in different outcome as measured by NSE release in SCA survivors. Bleeding complications were more frequently encountered by invasive cooling.

Cited by 76 publications

References 34 publications

Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest

Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest

Practice guideline summary: Reducing brain injury following cardiopulmonary resuscitation

In-Hospital Cardiac Arrest

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