Hypothermia After Cardiac Arrest: Where Are We Now? David A. Pearson, MD, MS Associate Professor Director of Cardiac Arrest Resuscitation Carolinas HealthCare System
Disclosures I have no financial interest, arrangement, or affiliations and no commercial interests, ties, or grants related to material covered in this lecture. 2
Objectives Institute of Medicine (IOM) Report & AHA 2015 Updates Targeted temperature management Regionalization & Systems of care: Code Cool 3
8 Ways To Improve Survival: 1. Establish a national cardiac arrest registry. 2. Foster a culture of action through public awareness and training. 3. Enhance the capabilities and performance of EMS systems. 4. Set national accreditation standards related to cardiac arrest for hospitals and health care systems. 5. Adopt continuous quality improvement programs. 6. Accelerate research on pathophysiology, new therapies, and translation of science for cardiac arrest. 7. Accelerate research on evaluation & adoption of CA therapies. 8. Create a national cardiac arrest collaborative. 4
AHA 2015: IHCA & OHCA Chains of Survival 5
6 Safar P, 1961.
7 Pre-Hospital Cooling
AHA 2015: Pre-hospital Cooling 8
1359 patients (583 with VF, 776 without VF) Decreased core temp by 1.20 C & 1.30 C No difference in survival or neurological status Re-arrest in field, pulmonary edema, diuretic use higher w/ cold IVF (26% vs 21%, p=.008) Kim et al. JAMA 2013.
Pre-hospital Cooling: North Carolina 847 patients in 2012 55% received pre-hospital hypothermia Pre-hospital initiation of hypothermia: OR 1.55 Improved neuro outcome @ discharge: OR 1.56 Rao MP et al. Prehosp Emerg Care. 2016 10
Intra-Arrest Cooling Trans-nasal evaporative cooling, ice packs, cold IVF Improves defibrillation success? Mortality & neurological outcome? 11
TARGETED TEMPERATURE MANAGEMENT
AHA 2015 Guidelines: Targeted Temperature Management 13
14 Landmark Trials
Landmark Trials Europe RCT n=275, 9 centers OOH witnessed VT/VF ROSC < 60min No purposeful response MAP > 80 mmhg 24 hr cooling to 32-34 C Australia RCT n=77, 4 centers OOH witnessed VF ROSC GCS < 7 Pre-hospital cooling 12 hr cooling to 33 C 15 HACA Study Group. NEJM 2002. Bernard SA, et al. NEJM 2002.
Survival with Good Neuro Outcome
939 comatose out-of-hospital cardiac arrest patients Randomly assigned: 33 C vs 36 C Outcomes: All-cause mortality Poor neurological function at 180 days Nielsen et al. NEJM. 2013.
Survival with Good Neuro Outcome 60% 50% 40% 30% 20% 33 C Not 33 C 10% 0% HACA Australian TTM
950 unconscious adults 939 included Mini-Mental State Examination (MMSE) MMSE 6 months after cardiac arrest No difference with 33C vs 36C 66.5% at 33C vs 61.8% at 36C (p=0.32) with complete mental recovery 20
26,183 patients: Mar 2002 Dec 2014 1568 (6%) treated with therapeutic hypothermia TH associated with LOWER in-hospital survival (27.4% vs 29.2%; 95% CI: 0.80 to 0.97) TH associated with LOWER favorable neuro survival (17.0% vs 20.5%; 95% CI: 0.69 to 0.90) 21
Cool Questions Optimal time to initiate cooling? Optimal method of cooling? Optimal rate of cooling? Optimal temperature? Optimal duration? 22
AHA 2015 Guidelines 23
AHA 2015 Guidelines 24
Minneapolis Experience 140 out-of-hospital cardiac arrest patients ROSC < 60 minutes Included: any initial rhythm, HD instability, STEMI Excluded: DNR, active bleeding, comatose before arrest 51% good neurological outcome 25 Mooney, et al. Circulation. 2011.
CMC Experience Local: 46% good neurological outcome Referred: 39% good neurological outcome 26 Heffner, et al. AHJ. 2012.
Japanese Experience Second link (early defibrillation) most important Fifth link (multidisciplinary post-resuscitation care in a regional center) next most important 27
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AHA-Recommended Hospital Designation Level I Center: Cardiac Resuscitation Center Hypothermia PCI Critical care Level II Center: Cardiac Resuscitation Center Resuscitate Initiate cooling Transfer AICD assessment & placement 29
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1. Induction TTM - Stages Infuse 30 ml/kg 4 C NS IV rapid bolus Typically 2500 ml 15 ice packs to axilla, groin, neck, torso Administer paralytic IV push Initiate device (surface or internal) 2. Maintenance Achieve goal temperature of 33 C 36 C for relative contraindications or cooling intolerance Maintain for 24 hours 3. Rewarming Controlled: < 0.5 C/hour 4. Controlled normothermia
Induction Maintenance Surface (noninvasive) Medivance (now Bard Medical) Arctic Sun 2000, 5000 Internal (invasive) Zoll IVTM catheter Quattro, Icy, Cool Line
Code Cool Neurologic Outcome for Witnessed, Shockable Arrest Patients 2013/2014 Performance with 2015 Baseline and Target* 70% 65% 60% 55% 50% Stretch: 55.8% Target: 53.2% Baseline: 50.7% 45% 40% 35% 30% 25% 20% 2007 2008 2009 2010 2011 2012 2013 Jan - June 2014 *Includes all patients activated as code cool through the Physician Connection Line *Good neurologic outcome is defined as a CPC score of 1 or 2 33
Good Neuro Outcome: Witnessed Shockable Arrests 34
Final Thoughts Pre-hospital Cooling Out-of-hospital Cardiac Arrest Cooling In-hospital Cardiac Arrest Cooling Regionalization 35
Questions?