Variability in Postarrest Targeted Temperature Management Practice: Implications of the 2015 Guidelines

Leary, Marion; Blewer, Audrey L; Delfin, Gail; Abella, Benjamin S.

doi:10.1089/ther.2015.0027

Cited by 8 publications

(3 citation statements)

References 21 publications

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“…trauma and stroke (Karaszewski et al, 2009;Childs and Lunn, 2013). Since the landmark TTM trial showing equivalent effects of treatment at 33°C versus 36°C on patient outcomes (Nielsen et al, 2013), clinical practice has shifted toward targeting 36°C in comatose survivors of cardiac arrest Leary et al, 2015;Deye et al, 2016). The TTM trial demonstrated equivalent patient outcomes at a population level, yet even within the context of this trial the 95% error bars in the 36°C cohort crossed 37°C (Nielsen et al, 2013).…”

Section: Discussionmentioning

confidence: 99%

Concordance of Brain and Core Temperature in Comatose Patients After Cardiac Arrest

Coppler

Marill

Okonkwo

et al. 2016

Therapeutic Hypothermia and Temperature Management

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Comatose patients after cardiac arrest should receive active targeted temperature management (TTM), with a goal core temperature of 32-36°C for at least 24 hours. Small variations in brain temperature may confer or mitigate a substantial degree of neuroprotection, which may be lost at temperatures near 37°C. The purpose of this study was to define the relationship between brain and core temperature after cardiac arrest through direct, simultaneous measurement of both. We placed intracranial monitors in a series of consecutive patients hospitalized for cardiac arrest at a single tertiary care facility within 12 hours of return of spontaneous circulation to guide postcardiac arrest care. We compared the absolute difference between brain and core (esophageal or rectal) temperature measurements every hour for the duration of intracranial monitoring and tested for a lag between brain and core temperature using the average square difference method. Overall, 11 patients underwent simultaneous brain and core temperature monitoring for a total of 906 hours of data (Median 95; IQR: 15-118 hours per subject). On average, brain temperature was 0.34C° (95% confidence interval [CI] 0.31-0.37) higher than core temperature. In 7% of observations, brain temperature exceeded the measured core temperature ≥1°C. Brain temperature lagged behind core temperature by 0.45 hours (95% CI = -0.27-1.27 hours). Brain temperature averages 0.34°C higher than core temperature after cardiac arrest, and is more than 1°C higher than core temperature 7% of the time. This phenomenon must be considered when carrying out TTM to a goal core temperature of <36°C.

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Section: Discussionmentioning

confidence: 99%

Concordance of Brain and Core Temperature in Comatose Patients After Cardiac Arrest

Coppler

Marill

Okonkwo

et al. 2016

Therapeutic Hypothermia and Temperature Management

View full text Add to dashboard Cite

show abstract

“…The target temperature for TH varies widely due to the variability in the updated recommended goal temperatures (ranging from 32°C to 36°C) in the 2015 AHA Guidelines. It is reasonable that the target temperature be maintained for at least 24 hours after achieving target temperature [ 19 ]. In this case, the patient went on to an excellent clinical outcome after receiving therapeutic hypothermia following out-of-hospital cardiac arrest with an initially nonshockable rhythm (PEA) and 15 minutes of resuscitation.…”

Section: Discussionmentioning

confidence: 99%

Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest

Kashif

Hashmi

Khaja

2016

Case Reports in Critical Care

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Foreign body aspiration (FBA) is uncommon in the adult population but can be a life-threatening condition. Clinical manifestations vary according to the degree of airway obstruction, and, in some cases, making the correct diagnosis requires a high level of clinical suspicion combined with a detailed history and exam. Sudden cardiac arrest after FBA may occur secondary to asphyxiation. We present a 48-year-old male with no history of cardiac disease brought to the emergency department after an out-of-hospital cardiac arrest (OHCA). The patient was resuscitated after 15 minutes of cardiac arrest. He was initially managed with therapeutic hypothermia (TH). Subsequent history suggested FBA as a possible etiology of the cardiac arrest, and fiberoptic bronchoscopy demonstrated a piece of meat and bone lodged in the left main stem bronchus. The foreign body was removed with the bronchoscope and the patient clinically improved with full neurological recovery. Therapeutic hypothermia following cardiac arrest due to asphyxia has been reported to have high mortality and poor neurological outcomes. This case highlights the importance of early identification of FBA causing cardiac arrest, and we report a positive neurological outcome for postresuscitation therapeutic hypothermia following cardiac arrest due to asphyxia.

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“…The survey may not reflect the entire range or actual clinical care across individual practitioners at each site. Reported variation may be greater at the provider level than the site level (Leary et al, 2015;Deye et al, 2016;Kotini-Shah et al, 2016). Additionally, comparing a smaller US cohort to a larger Korean cohort may not reflect all variability between these countries.…”

Section: Limitationsmentioning

confidence: 99%

Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators

Coppler

Sawyer

Youn

et al. 2017

Therapeutic Hypothermia and Temperature Management

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There is little consensus regarding many post-cardiac arrest care parameters. Variability in such practices could confound the results and generalizability of post-arrest care research. We sought to characterize the variability in post-cardiac arrest care practice in Korea and the United States. A 54-question survey was sent to investigators participating in one of two research groups in South Korea (Korean Hypothermia Network [KORHN]) and the United States (National Post-Arrest Research Consortium [NPARC]). Single investigators from each site were surveyed (N = 40). Participants answered questions based on local institutional protocols and practice. We calculated descriptive statistics for all variables. Forty surveys were completed during the study period with 30 having greater than 50% of questions completed (75% response rate; 24 KORHN and 6 NPARC). Most centers target either 33°C (N = 16) or vary the target based on patient characteristics (N = 13). Both bolus and continuous infusion dosing of sedation are employed. No single indication was unanimous for cardiac catheterization. Only six investigators reported having an institutional protocol for withdrawal of life-sustaining therapy (WLST). US patients with poor neurological prognosis tended to have WLST with subsequent expiration (N = 5), whereas Korean patients are transferred to a secondary care facility (N = 19). Both electroencephalography modality and duration vary between institutions. Serum biomarkers are commonly employed by Korean, but not US centers. We found significant variability in post-cardiac arrest care practices among US and Korean medical centers. These practice variations must be taken into account in future studies of post-arrest care.

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Variability in Postarrest Targeted Temperature Management Practice: Implications of the 2015 Guidelines

Cited by 8 publications

References 21 publications

Concordance of Brain and Core Temperature in Comatose Patients After Cardiac Arrest

Concordance of Brain and Core Temperature in Comatose Patients After Cardiac Arrest

Early Recognition of Foreign Body Aspiration as the Cause of Cardiac Arrest

Variability of Post-Cardiac Arrest Care Practices Among Cardiac Arrest Centers: United States and South Korean Dual Network Survey of Emergency Physician Research Principal Investigators

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