Targeted Temperature Management and Multimodality Monitoring of Comatose Patients After Cardiac Arrest

Abstract

Out-of-hospital cardiac arrest (CA) remains a leading cause of sudden morbidity and mortality; however, outcomes have continued to improve in the era of targeted temperature management (TTM). In this review, we highlight the clinical use of TTM, and provide an updated summary of multimodality monitoring possible in a modern ICU. TTM is neuroprotective for survivors of CA by inhibiting multiple pathophysiologic processes caused by anoxic brain injury, with a final common pathway of neuronal death. Current guidelines recommend the use of TTM for out-of-hospital CA survivors who present with a shockable rhythm. Further studies are being completed to determine the optimal timing, depth and duration of hypothermia to optimize patient outcomes. Although a multidisciplinary approach is necessary in the CA population, neurologists and neurointensivists are central in selecting TTM candidates and guiding patient care and prognostic evaluation. Established prognostic tools include clinal exam, SSEP, EEG and MR imaging, while functional MRI and invasive monitoring is not validated to improve outcomes in CA or aid in prognosis. We recommend that an evidence-based TTM and prognostication algorithm be locally implemented, based on each institution's resources and limitations. Given the high incidence of CA and difficulty in predicting outcomes, further study is urgently needed to determine the utility of more recent multimodality devices and studies.

Exploring Trends in Neuromonitoring Use in a General Pediatric ICU: The Need for Standardized Guidance

“…Of these 420 patients, 331 (78.8%) had a primary neurological diagnosis. These diagnoses included traumatic brain injury (57), brain tumor (54), seizures/status epilepticus (46), hydrocephalus/increased ICP (35), ischemic or hemorrhagic stroke (29), epilepsy surgery (25), meningitis/encephalitis (23), out-of-hospital cardiac arrest or drowning (14), spinal cord injury or lesion (12), other postoperative neurosurgery (30), and other medical neurological diagnoses (6). Furthermore, of the 420 patients who received neuroimaging or neuromonitoring, 89 (21.2%) had a primary non-neurological diagnosis.…”

“…Frameworks for clinical practice using multimodal monitoring and physiologic goal-directed treatment are becoming more prevalent in adult brain injury and might improve neurologic outcomes [ 10 ]. Some clinical guidance and thresholds exist for neuromonitoring technologies in adult populations, such as cerebral near-infrared spectroscopy (NIRS), transcranial doppler (TCD), and electroencephalogram (EEG) in post-cardiac arrest and extracorporeal membrane oxygenation (ECMO) [ 11 , 12 , 13 ]. Similarly, neuromonitoring has noted benefits in anesthesia for certain intraoperative settings [ 14 ].…”

Thermoregulation: A journey from physiology to computational models and the intensive care unit

“…Lastly, shivering, which is a side effect of hypothermia, must be managed adequately to avoid temperature rise. The patient should therefore be sedated and paralyzed to reduce its undesirable effects (Leong et al, 2017; Nguyen et al, 2018).…”

Urinary Proteome Analysis of Global Cerebral Ischemia–Reperfusion Injury Rat Model via Data-Independent Acquisition and Parallel Reaction Monitoring Proteomics

“…To date, the diagnosis and evaluation of global cerebral I/R injury have mainly relied on clinical symptoms, neuroimaging, electrophysiology, and biochemical examination of blood or cerebrospinal fluid. However, hemodynamic instability, sedation, and hypothermia are common in these patients, limiting the application of these tests (Nguyen et al 2018 ). The main clinical treatment methods include supportive therapy, symptomatic treatment, mild hypothermia, and hyperbaric oxygen therapy.…”