Enhancing 5 th Chain TTM after Cardiac Arrest
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1 Enhancing 5 th Chain TTM after Cardiac Arrest Seoul St. Mary s Hospital Department of Emergency Medicine Chun Song Youn
2 Agenda Past Current Future
3
4 First study, 1958
5 2002, Two landmark paper
6 HACA Trial N Engl J Med. 2002;346(8):
7 Phases of TH
8
9 2015 AHA Guideline Comatose & adult patients with ROSC after cardiac arrest have TTM (Class I) OHCA and IHCA Selecting and maintaining a constant temperature between 32ºC and 36ºC during TTM (Class I). TTM be maintained for at least 24 hours after achieving target temperature (Class IIa).
10 Who should be cooled? Which device is better? One size fit all? How early? Optimal target temperature? Duration - how long? How slowly? Controlled normothermia - how long?
11 Cooling Methods Internal Cooling Surface Cooling
12 Data from KORHN Multicenter Retrospective Registry Propensity matched analysis Hospital mortality 34.4% vs 38.3% (p=0.44) Poor neurologic outcome 70.0% vs 65.0% (p=0.31) No Difference Crit Care 2015;19:e85
13 ICEREA Study Multicenter RCT in France, Endovascular vs Surface, N=400 Favorable outcome at day 28 No difference, P=0.107 Endovascular Surface Circulation 2015;132:
14 Intra-arrest Cooling Circulation 2004;109:
15 Circulation 2010;122: Tympanic temperature Core temperature
16 PRINCE Trial
17 Prehospital Cold Saline RCT in USA, 2L of 4C saline vs standard, N=1364 Survival and neurologic outcome : No difference Re-arrest & Pulmonary edema : increased in cold saline group JAMA. 2014;311(1):45-52.
18 RINSE Trial RCT in Australia, 2L of cold saline vs standard, N=1198 Temperature: lower in cold saline group (34.7 vs 35.4, p<0.001) Transported with ROSC in shockable rhythm : lower in cold saline group (41.2% vs 50.6%, p=0.03) Pulmonary edema : increased in cold saline group (10.0% vs 4.5%, p<0.001) Circulation 2016;134:
19 TTM Trial, 33 vs 36 Multicenter RCT, N=950 No difference in survival and neurologic outcome Witness 90%, Bystander CPR 73%, Shockable 80% arrest to CPR 1min, Down time 25min N Engl J Med 2013; 369:
20 HACA vs TTM Mild fever is harmful 33 is more protective than 36?
21 HYPERION Trial, multicenter RCT for non-shockable rhythm
22 TTH48 Trial Multicenter RCT in Europe, N=350 Primary outcome : neurologic outcome at 6months NCT Trials (2016) 17:228
23 One size does not fit all Which device is better? ICEREA Study et al. Rewarming Rate? Post-rewarming normothermia? Pre-hospital cooling Kim F, JAMA 2014;311:45-52 RINSE Trial Intra-arrest cooling (PRINCE Trial) Optimal target temperature? TTM Trial (33 vs 36) HYPERION Trial Optimal duration? TTH48 Trial
24
25 Injury Severity Ischemic-Reperfusion Injury 33 = > > = 36 Some Patients can regain consciousness Some Patients can regain consciousness Some Patients can not regain consciousness regardless of target temperature when treated with 33 or when treated with 36 regardless of target temperature
26 Injury Severity Any surrogate marker for injury severity? Initial rhythm? Anoxic time? PCAS category? OHCA score? APACHE II? N/Ex. after ROSC? Brain CT after ROSC?
27 Kagawa et al. Single center, Retrospective N=400 Primary outcome : CPC at hospital discharge CPA-ROSC : arrest to ROSC TH is more beneficial when CPA-ROSC 15min Critical Care 2010;14:R155
28 Testori et al. Retrospective cohort study N=1200 (TH=598, no TH=602) No flow time : arrest to CPR TH effect when no flow time Resuscitation 2012;83:
29 Wallmuller et al. Retrospective cohort study N=1103 (TH=613) Low-flow time : CPR - ROSC TH effect when low-flow time is low to moderate Resuscitation 2016;98:15-9
30 HYPERION Trial Investigators
31 ILCOR Advisory Statement Are there subpopulations in which aggressive prevention of fever instead of targeted temperature management (32 C 36 C) is justified? Are there subpopulations in which a temperature of 32 C to 34 C is beneficial compared with 36 C? For example, are patients with more severe neurological injury more likely to benefit from a lower target temperature? Are there subpopulations in which a temperature of 36 C is beneficial compared with 32 C to 34 C such as patients with hemodynamic instability or bleeding?
32 I still recommend
33 감사합니다
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