Feasibility of early waking cardiac arrest patients whilst receiving therapeutic hypothermia: The therapeutic hypothermia and early waking (THAW) trial

Abstract

Aim: To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM). Methods: This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment. Results: 50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0-2. The overall intra-hospital mortality was 50% (n = 25). Conclusions: It is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

“…However, current data evaluating this strategy are limited, and it requires more formal study. [ 49 ] A finding of unobstructed coronary arteries can also be of use in understanding the aetiology of the OHCA even though it cannot exclude all ischaemic aetiologies, such as coronary vasospasm or embolic disease. Hence, it is recommended that clinical discretion is used when considering immediate invasive coronary angiography, particularly in patients without STEMI.…”

MIRACLE2 and SCAI grade identify patients for early wakening after out-of-hospital cardiac arrest: a post hoc analysis of the THAW trial

“…MIRACLE 2 and SCAI grade identify patients for early wakening after out-of-hospital cardiac arrest: a post hoc analysis of the THAW trial Rupert Simpson 1,2 , Grigoris V. Karamasis 1,3 , John Davies 1,2 , Nilesh Pareek 4,5 , Thomas R. Keeble 1,2* Out-of-hospital cardiac arrest (OHCA) is a major unmet clinical need, with the majority of patients dying due to neurological injury [1]. Traditionally, patients were sedated and ventilated for 36 h to facilitate therapeutic hypothermia (TH) followed by neurological prognostication 72 h after admission [2].…”

“…We conducted a post hoc analysis of the Therapeutic Hypothermia and eArly Waking (THAW) trial [4]. This study was designed to assess safety and feasibility of discontinuing sedation and paralysing medication for early evaluation of neurological status and extubation in OHCA survivors.…”

“…This study was designed to assess safety and feasibility of discontinuing sedation and paralysing medication for early evaluation of neurological status and extubation in OHCA survivors. At 11 h suitability for early waking was assessed, based on cardiovascular (stable haemodynamics, single inotropic support), respiratory (blood gas exchange normal, Fi02 < 0.5 and PEEP 5-8 cmH 2 0), neurological (pupils equal, reactive, withdrawing to painful stimuli and no evidence of seizure activity) and metabolic (urine output > 0.5 ml/kg, normal sodium and potassium) status [4]. If suitable, neuromuscular blocking agents were discontinued, sedation weaned and anti-shivering regime commenced prior to attempted extubation.…”