Nutrition During Targeted Temperature Management After Cardiac Arrest: Observational Study of Neurological Outcomes and Nutrition Tolerance

Abstract

Background: Whether providing nutrition support is beneficial or deleterious during targeted temperature management (TTM) after cardiac arrest is unclear. We therefore performed a retrospective observational study to determine whether early nutrition was beneficial or deleterious during TTM. Methods: We retrospectively studied patients admitted to our intensive care unit (ICU) between 2008 and 2014 after successfully resuscitated cardiac arrest. We compared the group given nutrition within 48 hours after ICU admission (E+ group) to the group given nutrition later on or not at all (E-group). Results: Of the 203 included patients, 143 were in the E+ group and 60 in the E-group. The E+ group had a significantly higher proportion of patients with a good 3-month neurological outcome (42.7% vs 16.7%, P < 0.001). The difference remained significant after adjustment on a propensity score (odds ratio, 3.47; 95% confidence interval, 1.48-8.14; P = 0.004). The cumulative energy deficit for an energy goal of 20 kcal/kg/d from admission to day 7 was significantly lower in the E+ group (3304 ± 2863 kcal vs 5017 ± 2655 kcal, P < 0.001). Within the E+ group, the subgroups with nutrition initiation when body temperature was <36°C vs ࣙ36°C were not significantly different regarding the frequencies of early-onset pneumonia, ventilator-associated pneumonia, vomiting, and prokinetic drug use (all P-values > 0.05). Conclusions: Early nutrition after cardiac arrest during TTM appears safe and may be associated with better neurological outcomes. These findings warrant a randomized controlled trial to resolve the remaining issues. (JPEN J Parenter Enteral Nutr. 2020;44:138-145) Keywords cardiac arrest; induced hypothermia; nutrition; pneumonia; targeted temperature management Clinical Relevancy StatementPatients comatose after cardiac arrest are admitted to the intensive care unit (ICU) for targeted temperature management and neurological prognostication. Whether providing From the

Outcomes associated with delayed enteral feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and targeted temperature management

“…Finally, the rate of pneumonia differs widely in the literature ranging from 65% when initial aspiration pneumonia is included to 10À22% later in hospitalization. 20,32 We found that the occurrence of pneumonia after 5 days of admission was 23.3%, which is within the reported range. Timing of feeding initiation did not change the rate of pneumonia.…”

“…17,19,40 However, given concerns for bowel ischemia and increased risk of pneumonia, feeding initiation is frequently delayed in critically ill patients. 18,20,32 Multiple studies have examined the effects of early nutrition in cardiac arrest populations. In a retrospective analysis Joo et al looked at more than 400 propensity score matched patients with out-ofhospital cardiac arrest receiving TTM including 13% who were also supported with ECMO.…”

“…32 In another retrospective study of adults admitted for TTM after cardiac arrest, early initiation of nutrition (initiated within 48 h of admission) was associated with improved mortality (OR 0.35; CI 0.2À0.5) and better 3-month neurologic outcomes as assessed by CPC 1À2 (OR 3.47; CI 1.48À8.14) compared to late enteral feeding. 20 Importantly, in both of these studies, patients who did not receive enteral feeding were included in the delayed feeding group. There are two important differences between the above studies and our present results.…”

“…Combining the group who is never fed with the delayed nutrition cohort is likely to decrease the latter group's apparent survival. 20,32 When we included patients who were not fed at any time in the delayed feeding group, the significant difference in mortality (55.9% versus 69.4%, OR 0.56; 95% CI 0.25, 1.23; p = 0.15) and neurologically favorable survival (55.9% vs 49.1%; OR 0.92; 95% CI 0.39,2.16; p = 0.85) was negated.…”

Impact of rewarming rate on interleukin-6 levels in patients with shockable cardiac arrest receiving targeted temperature management at 33 °C: the ISOCRATE pilot randomized controlled trial

“…Another retrospective cohort study found no significant difference in the Glasgow Outcome Scale score at 6 months between the groups with rewarming rates < 0.5 °C/h or ≥ 0.5 °C/h [ 26 ]. Differences in case-mix and in care delivered during TTM [ 15 , 27 ], together with residual confounding, complicate the interpretation of these results. This probably explains why the 2021 update of guidelines for cardiac arrest make no recommendations about the rewarming rate [ 7 ].…”