Rapid implementation of therapeutic hypothermia in comatose out‐of‐hospital cardiac arrest survivors

Abstract

Background: The implementation of therapeutic hypothermia (TH) into daily clinical practice appears to be slow. We present our experiences with rapid implementation of a simple protocol for TH in comatose out-of-hospital cardiac arrest (OHCA) survivors. Methods: From June 2002, we started cooling pre-hospitally with sport ice packs in the groin and over the neck. In the intensive care unit (ICU), we used ice-water soaked towels over the torso. All patients were endotracheally intubated, on mechanical ventilation and sedated and paralysed. The target temperature was 33 AE 1 8C to be maintained for 12-24 h. We used simple inclusion criteria: (i) no response to verbal command during the ambulance transport independent of initial rhythm and cause of CA; (ii) age 18-80 years; and (iii) absence of cardiogenic shock (SBP < 90 mmHg despite vasopressors). We compared the first 27 comatose survivors with a presumed cardiac origin of their OHCA with 34 historic controls treated just before implementation. Results: TH was initiated in all 27 eligible patients. The target temperature was reached in 24 patients (89% success rate). ICUand hospital-length of stay did not differ significantly before and after implementation of TH. Hypokalemia (P ¼ 0.001) and insulin

Scandinavian Clinical practice guidelines for therapeutic hypothermia and post‐resuscitation care after cardiac arrest

“…There have also been several previous studies with historical controls [25][26][27] considered as GOE IV, and experimental studies. [28][29][30][31] Recently, several observational studies, with historical controls [32][33][34][35] (GOE IV), uncontrolled studies 36,37 (GOE V) and a European registry 39 (GOE V), all show that MTH is feasible, safe, has few side effects and seems to contribute toward improved survival.…”

“…Induction can easily be induced with ice-cold i.v. fluids (30-40 ml/kg) 35,[47][48][49][50] (GOE II-V) or removal of clothes and with the use of ice packs, placed in the groins, armpits and around the neck and head 33,51 (GOE IV and II). Although traditional external cooling has proven its feasibility 33,51,52 (GOE IV, V, II), its use may lead to overcooling 53 (GOE V).…”

“…A European hypothermia registry study 39 (GOE V) reported that the majority of the patients were MTH treated for 24 h. However, 12-h protocols have also been used. 23,33 Newborns with asphyctial cardiac arrest have been successfully treated for 72 h 41,42 (GOE I), and it may be that even adults with a severe reperfusion injury due to hypoxic-induced cardiac arrest should be treated with MTH of a longer duration. Further studies are warranted to address this important question.…”

Out‐of‐hospital cardiac arrest: studies on aetiology, treatment and outcome

“…In a Norwegian study, prehospital cooling was initiated in the field with sport ice-packs and continued with ice-water soaked towels over the torso in ICU. This method is also inexpensive and easily implemented in any system (Busch et al 2006). Now ice-cold intravenous fluids should be applied to induce hypothermia in survivors of OHCA (Mayer 2005).…”

Erweiterte Reanimationsmaßnahmen für Erwachsene („advanced life support“)

“…In den ersten 48 h nach Kreislaufstillstand ist eine hypertherme Phase typisch (Hyperpyrexie; [696,697,698] [709]. Sechs Studien mit historischen Kontrollgruppen wiesen den Nutzen der therapeutischen Hypothermie bei komatösen Überlebenden eines präklinischen Kreislaufstillstands aufgrund aller EKG-Rhythmen nach [630,633,710,711,712,713]. Zwei nichtrandomisierte Studien mit gleichzeitig durchgeführten Kontrollen deuten auf einen möglichen Nutzen der Hypothermie nach einem präklinischen und innerklinischen Kreislaufstillstand infolge anderer initialer Herzrhythmen hin [714,715].…”