Targeted temperature management for postcardiac arrest syndrome

Abstract

Neurocritical care management to improve neurologic outcome for postcardiac arrest syndrome (PCAS) has focused considerably on targeted temperature management (TTM). TTM attenuates the destructive processes following ischemia/reperfusion in PCAS. The principal indication of TTM is a patient with sustained coma after return of spontaneous circulation (ROSC). TTM can be strongly recommended with a target temperature between 32°C and 36°C for patients with shockable rhythm and out-of-hospital cardiac arrest (OHCA) and weakly recommended for patients with initial asystole or pulseless electrical activity with OHCA and those with in-hospital cardiac arrest. TTM is induced and maintained using a cooling device with body temperature feedback under appropriate analgosedation. It requires the intensive management of various systemic respiratory, circulatory, and metabolic parameters that control shivering to prevent secondary brain damage. Considering the cerebral perfusion pressure, it is suggested that the mean arterial pressure should be particularly maintained over 80 mm Hg. Seizure management, including continuous electroencephalography monitoring, is also needed. Finally, we must continue the above mentioned care during and after the rewarming phase, because high fever and shivering may appear again during this period. Furthermore, neurological prognostication should be performed at least 72 hours after ROSC through clinical investigations and multimodal testing without sedation.

Pre Versus Post Implementation of a Pharmacologic Antishivering Protocol During Targeted Temperature Management Following Cardiac Arrest

“…Minimizing shivering during TTM is important to reduce secondary brain injury and to maintain efficacy of TTM following cardiac arrest [ 1 , 8 ]. Although guidelines recognize the importance of adequately controlling shivering, they provide minimal guidance on a concrete approach, stemming from a paucity of data.…”

“…Following cardiac arrest, cerebral ischemia occurs within 5 min of cessation of cerebral blood flow, leading to a cascade of deleterious reactions that result in neurologic injury. Secondary neurologic injury begins immediately after return of spontaneous circulation (ROSC) and persists for hours and days following cardiac arrest, further exacerbating neurologic insult [ 1 , 2 ]. Targeted temperature management (TTM) has been shown in two randomized controlled trials to improve neurologic outcomes (with one trial demonstrating improved survival) in patients who remain in a coma following ROSC.…”

“…Shivering is a major complication of TTM and is the body’s innate thermoregulatory response to decreases in core body temperature below a threshold of approximately 36 °C. Shivering can negate the neuroprotective benefits of TTM by increasing systemic and cerebral energy consumption, increasing metabolic demand, and making it difficult to achieve and maintain target temperature [ 1 , 2 , 8 ]. The incidence of shivering is reported to occur in up to 40% of patients undergoing TTM, yet despite the high incidence of shivering and negative consequences, consensus guidelines provide minimal guidance on the management of shivering [ 3 – 5 , 9 ].…”

Target temperature management in traumatic brain injury with a focus on adverse events, recognition, and prevention

“… Shivering management [ 19 , 27 ]. Continuous electroencephalogram monitoring may be considered for early detection of nonconvulsive status epilepticus for Stages 2 and 3.…”

Emerging Trends in the Use of Therapeutic Hypothermia as a Method for Neuroprotection in Brain Damage (Review)

“…Nielsen et al [ 8 ] were the first to introduce the concept of controlled target temperature, which comprises a wider temperature range (33–36°C) compared to therapeutic hypothermia and exerts a better effect on brain lesions. Moreover, the use of a target temperature has become increasingly widespread in cardiac surgery in patients with cardiac arrest to prevent anoxic brain damage [ 9 ]. Controlled target temperature in the range of 32–36°C for 24–48 h is one of the standard treatment algorithms in comatose patients after out-of-hospital cardiac arrest [ 10 ].…”