Download - Update on Targeted Temperature Management
Targeted Temperature Management
Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham
Pegasus Emergency Group
Is It Still “Cool” to Cool or Is It “Hot” to Not
OR
Objectives• Discuss history of hypothermia in
acute cardiac events• Evaluate the
advantages/disadvantages of hypothermia in post-arrest management
• Critically evaluate current literature regarding temperature end-points
• Discuss future trends of TTM
Case Reports• 1980 - Annals of Internal Medicine– 2 case reports of hypothermic
immersions
Sekar TS. Arch Intern Med. 1980;140(6):775-779.
Benefits of Therapeutic Hypothermia
• Lowers tissue oxygen requirements
• Decreases cerebral metabolism and edema
• Improved tolerance to ischemia
• Decreases reperfusion inflammatory cascade Young RSK. JAMA. 1980;244:1233-1235 Globus MY. J Neurochem. 1995;65(4):1704-1711Busto R. Stroke. 1989;28(8):1113-1114
Breakthrough came in 2002
HACA Trial• 275 patients• 32-34o C vs
normothermia for 24 hr
• Primary Outcome– Neurologic function at
6 months
Bernard Trial• 77 patients• 33o vs 37o for 12
hr• Primary Outcome– Favorable
discharge location
HACA Investigators. NEJM. 2002;346(8):549-556. Bernard SA. NEJM. 2002;346(8):557-563.
Results of Initial Hypothermia Trials
HACA Investigators. NEJM. 2002;346(8):549-556. Bernard SA. NEJM. 2002;346(8):557-563.
Trials Criteria MortalityGood
Neurologic Outcomes
HACA
VT/VF rhythmResuscitation within 15minROSC within 60min32-34o for 24hr
Control – 55%Hypothermia – 41%
Control – 39%Hypothermia – 55%
Bernard
VF with persistent coma33o within 2hr for 12hr
Control – 68%Hypothermia – 51%
Control – 26%Hypothermia – 49%
Logistics of Therapeutic Hypothermia
Nolan JP. Circulation. 2003;108:118-121
When do you start cooling?
ASAP p ROSCSchwartz BG. Am J Cardio. 2012;110:461-466
Logistics of Therapeutic Hypothermia
Nolan JP. CIrculation. 2003;108:118-121
How long should patients be cooled?
Logistics of Therapeutic Hypothermia
Nolan JP. CIrculation. 2003;108:118-121
How fast do you re-warm?
0.5o/hr to 37o C
Logistics of Therapeutic Hypothermia
Nolan JP. CIrculation. 2003;108:118-121
Medications Monitoring
Hye JK. K J Anes. 2008;54(6):623-628
Prognosis Following Therapeutic Hypothermia
Taccone FS. Critical Care. 2014;18:202Bouwes A. Ann Neurol. 2012;71(2):206-212
Prognosis Following Therapeutic Hypothermia
Taccone FS. Critical Care. 2014;18:202Bouwes A. Ann Neurol. 2012;71(2):206-212
Complications of Therapeutic Hypothermia
Nolan JP. CIrculation. 2003;108:118-121 Schwartz BG. Am J Cardio. 2012;110:461-466
Targeted Temperature Management
• 939 patients in 36 ICU across Europe and Australia
• ***ALL RHYTHMS***• 2 study groups• Protocol• Outcomes– Primary – All cause mortality– Secondary – Neurologic status
Nielson N. NEJM. 2013;369:2197-2206
Targeted Temperature Management
Nielson N. NEJM. 2013;369:2197-2206
Outcome 33o Group
36o Group
HR/RR (95% CI)
P-value
Primary OutcomeDeath at end of trial 235/473
(50%)225/466 (48%)
1.06 (0.89-1.28) 0.51
Secondary outcomeNeurologic function at 180d CPC of 3-5 251/469
(54%)242/464 (52%)
1.02 (0.88-1.16) 0.78
MRS of 4-6 245/469 (52%)
239/464 (52%)
1.01 (0.89-1.14) 0.87
Death at 180d 226/473 (48%)
220/466 (47%)
1.01 (0.87-1.15) 0.92
Primary OutcomeNo difference in all-cause mortality
Secondary OutcomeNo difference in neurologic status
Shorter ICU and hospital stays in 36o group
TTM Protocol
1. 24 hours at 36o C2. 12 hours at 37o C3. 36 hours at 37.5o C (de-sedate)4. 36 hours at whatever (no sedation)
Prognosticate after 108 hours following ROSC
What Does This Mean Now?• 33o is not better than 36o
• Not just for VT/VF
• Easier on smaller hospitals
• Decreased hospital LOS
Future Considerations• What temperature is best?
• When to start cooling?
• Duration of cooling?
• Any complications with 36o?