Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest

Thenayan, Eyad Al; Savard, Martin; Sharpe, Michael D.; Norton, Loretta; Young, Bradley W.

doi:10.1212/01.wnl.0000334205.81148.31

Cited by 216 publications

(130 citation statements)

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“…In the aforementioned study, patients treated with TTM did not recover if pupillary response to light and corneal reflexes were absent up to 5 d [184] . Similar findings have been previously reported [182] . Notably, Fugate et al [184] reported no patient with a spontaneous downward gaze survived.…”

Section: Indications For Ttmsupporting

confidence: 93%

“…In fact, this study found a motor score on the Glasgow Coma Scale (GCS) ≤ 2, or decerebrate/extensor posturing, has a false-positive prediction of mortality of 24% at 36-72 h. However, the specifics of type, amount, and duration of sedatives were not reported in this study, complicating its interpretation. These motor findings have been previously reported in smaller studies [182,183] . In another study comparing predictors of recovery in CA patients treated with and without TTM at a single center, of 14 patients with a motor score ≤ 2 at day two, 2 survived with a good or moderate outcome as scored by the Cerebral Performance Categories Score (CPC) [184] .…”

Section: Indications For Ttmsupporting

confidence: 90%

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Use of hypothermia in the intensive care unit

Corry¹

2012

WJCCM

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Used for over 3600 years, hypothermia, or targeted temperature management (TTM), remains an ill defined medical therapy. Currently, the strongest evidence for TTM in adults are for out-of-hospital ventricular tachycardia/ventricular fibrillation cardiac arrest, intracerebral pressure control, and normothermia in the neurocritical care population. Even in these disease processes, a number of questions exist. Data on disease specific therapeutic markers, therapeutic depth and duration, and prognostication are limited. Despite ample experimental data, clinical evidence for stroke, refractory status epilepticus, hepatic encephalopathy, and intensive care unit is only at the safety and proof-of-concept stage. This review explores the deleterious nature of fever, the theoretical role of TTM in the critically ill, and summarizes the clinical evidence for TTM in adults.

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Section: Indications For Ttmsupporting

confidence: 93%

Section: Indications For Ttmsupporting

confidence: 90%

Use of hypothermia in the intensive care unit

Corry¹

2012

WJCCM

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“…The ideal paradigm for prognosticating neurologic outcomes in comatose cardiac arrest survivors treated with TH is unknown despite several studies that have tried to shed light on this crucial question (12)(13)(14)(15)(16)(17)(18). These studies have several important flaws: a lack of blinding to the results of the prognostic markers being evaluated (13,16,(19)(20)(21)(22), the high proportion of patients who have withdrawal of life-sustaining therapy (WLST) (12,13,19,23), and a lack of understanding regarding the number of patients who die of a true neurologic cause defined brain death as opposed to WLST, cardiac, respiratory, infectious, or other causes.…”

mentioning

confidence: 99%

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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Objectives-To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia.Design-Single center, prospective observational cohort study of consecutive patients with outof-hospital cardiopulmonary arrests. Setting-Academic HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptPatients-Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU. Interventions-None.Measurements and Main Results-The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of lifesustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1-2) did so after 72 hours.Conclusions-Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death. Keywordsbrain death; cardiac arrest; outcome; prognostication; therapeutic hypothermia; withdrawal of lifesustaining treatmentOut-of-hospital cardiopulmonary arrests (OHCA) pose a significant public health burden, with an estimated annual prevalence of over 380,000 arrests evaluated by emergency medical services in the United States alone (1-4). In the decade following the 2002 landmark trials of therapeutic hypothermia (TH) to improve outcomes in comatose cardiac arrest survivors, little additional progress has been made in finding and implementing successful new neuroprotective interventions (5, 6). Therefore, TH remains the only proven neuroprotective strategy available and the focus of the resuscitation community. A number of factors explain this lack of progress: a lack of understanding of the mechanisms and circumstances leading to poor outcomes, lead time and selection biases, as well as funding and ethical co...

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“…Thenayan ve ark. (16) yaptıkları çalışmada, myoklonus status epileptikus görülmesinin, ilk üç gün-de IR ve KR yanıtının olmamasının kötü nörolojik prognoz ile ilişkili olduğunu göstermiştir. Olgularımızın hepsinde baş-langıçta olmayan IR yanıtının 24 saat içerisinde KR'nin ise ilk 3 gün içinde geri geldiği tespit edildi.…”

Section: Discussionunclassified

Endovascular Therapeutic Hypothermia After Cardiac Arrrest due to Acute Myocardial Infarction

Ozkan¹,

Koyuncu²,

Ozen³

et al. 2011

J Turk Anaesth Int Care

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ÖZETHastane dışı kardiyak arrest sonrası gelişen serebral hasar, morbidite ve mortalitenin önemli nedenidir. Hipotermi tedavisinin nörolojik prognoz üzerine olumlu etkisi gösterilmiş olmasına rağmen, ülkemizde rutin uygulamaya girmemiştir. Bu çalışmada kurumumuzda kardiyak arrest sonrası spontan dolaşım sağlanmasının ardından endovasküler soğutma ile tedavi edilen üç olgu bildirilecektir. Elli beş yaşında iki erkek ve 46 yaşında kadın üç olgunun ortalama hastaneye geliş süresi 15 dk., spontan dolaşım sağlanma (SDS) süresi 13,3 dk.'dır. Spontan dolaşım sağlandıktan sonra olguların GKS 3 idi ve beyin sapı refleksleri alınamıyordu. Femoral vene endovasküler soğutma kateteri (ALSIUS) yerleştirilerek hedef ısı 33°C olacak şekilde uygulama başlatıldı. Dolaşım kollapsından hipotermi başlangıcına kadar geçen ortalama süre 115 dk.'dır. Olgularımızda ortalama 285 dk.'da hedef ısıya ulaşıldı ve 18 saat bu ısıda izlendikten sonra yenidan ısıtma işlemine başlandı. Normotermi (36°C) 6 saat ortalama ile sağlandı ve komplikasyon gözlenmedi. Olgulara kranyal MR ve elektroensefalografi (EEG) incelemeleri yapıldı. İki olgunun 3. ve 6. ay Modifiye Rankin Skoru (mRS) 1, Glasgow-Pıttsburg Outcome Skoru (GPOS) 5 iken, dirençli myoklonik nöbetleri olan ve kranyal MR'da yaygın hipoksik hasarı tespit edilen üçüncü olgunun 3. ve 6 ay mRS 5, GPOS 2 olarak değerlendirildi. Kardiyak arrrest sonrası endovasküler terapötik hipotermi uygulanabilir ve güvenilir bir tedavi yöntemidir. Tedaviye erken başlanması ve hızlı bir şekilde hedef ısıya ulaşılması tedavinin etkinliği açısından önemlidir.Anahtar kelimeler: Kardiyak arrest, terapötik hipotermi, endovaskuler soğutma, eksternal soğutma, nörolojik prognoz SUMMARY Endovascular Therapeutic Hypothermia After Cardiac Arrrest due to Acute Myocardial InfarctionCerebral damage developing after out-of-hospital cardiac arrest, is a major cause of morbidity and mortality. Although hypothermic therapy demonstrated a positive effect on neurological outcomes, it is not yet in routine use in our country. In this study we reported three cases treated with endovascular cooling in our institution, following restoration of spontaneous circulation after out-of-hospital cardiac arrest. The mean return of spontaneous circulation (ROSC) time of 55-year-old two male, and a 46 year-old female patient were 15 and 13.3 minutes, respectively. Glascow coma score (GCS) was 3 points, and brain stem reflexes were absent in all cases. After placement of the cooling catheter (ALSIUS) into the femoral vein, the target temperature was set at 33°C. The average time between circulatory collapse and the start of hypothermic therapy was 115 minutes. The mean time to reach the target temperature was 285 minutes and rewarming was initiated after 18 hours. Normothermia (36°C) was achieved after an average of 6 hours and no complication was observed. Cranial MRI and electroencephalography (EEG) were performed. In two patients, 3 and 6 month-modified Rankin score (mRS) was 1, and Glasgow-Pittsburgh Outcome Score (GPOS) was 5. In the third...

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Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest

Cited by 216 publications

References 5 publications

Use of hypothermia in the intensive care unit

Use of hypothermia in the intensive care unit

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Endovascular Therapeutic Hypothermia After Cardiac Arrrest due to Acute Myocardial Infarction

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