European Journal of Emergency Medicine, Год журнала: 2023, Номер 31(2), С. 86 - 89
Опубликована: Дек. 21, 2023
Background Out-of-hospital cardiac arrest (OHCA) is the third leading cause of death in Europe, with a high burden disability for patients and their families [1]. When heart stops, body brain cells quickly deplete oxygen. Without intervention, damage occurs rapidly, inevitable. Unfortunately, prognosis OHCA remains poor, even when return spontaneous circulation (ROSC) achieved. Only few (less than 10%) can be discharged from hospital, only two-thirds these are good neurologic outcome to lead an independent life Reperfusion injury starts immediately following ROSC. Multiple pathophysiologic cascades reactive astrogliosis microglia activation neuronal by necrosis apoptosis. This one key component what has been described as 'post-resuscitation syndrome' [2]. Mild hypothermia temperature range 32 34°C was shown mitigate different simultaneously, efficiently limiting cell [3]. Numerous animal studies confirmed beneficial effect mild [4]. In 2002, two landmark randomized clinical trials (RCT) after shockable rhythm showed improved neurological outcomes treatment compared no control [5,6]. As result studies, 2005, European Resuscitation Council (ERC) guidelines recommended use 24 h unconscious adults resuscitated out-of-hospital rhythm; non-shockable in-hospital arrest, suggested weak recommendation [7]. One criticism original that groups [5,6] not strictly normothermic but slightly hyperthermic, around 37 38°C. prompted prospective trial comparing strict at 36°C 33°C (the targeted management TTM1 trial) [8]. published 2013 difference mortality between study groups. Consequently, ERC 2015 2021 extended post resuscitation target wider [9,10]. 2019, RCT normothermia 37°C [11]. 2021, further TTM2 early fever (body ≥37.8°C) [12]. same year, meta-analysis published, concluding TTM 34°C, normothermia, did [13]. latest cooperation Society Intensive Care Medicine (ESICM) preventing amended there insufficient evidence recommend or against 36°C, some subgroups may benefit such [14]. Critical appraisal current 2022 ERC/ESICM new scientific There number important limitations large [8,12], have greatly affected over last years. Firstly, rate bystander cardiopulmonary all 73 82%, which considerably higher average Europe 58% Observational data comparative analysis show short time, it case CPR, presumably less so might hypothermia, increases longer duration [15,16]. Secondly, both allowed delay up three four hours ROSC randomization, taken 7 achieve. injury, however, pathophysiology shows earlier cooling more effective. previous showing initiated ambulance service [6] median 105 min [5]. Thirdly, included many centers various countries, each center enrolling patients. creates potential considerable heterogeneity other aspects post-resuscitation care. For this reason, possible dose-response detected level heterogeneity. The recommendations on [14] predominantly based Granfeld et al. [13] [13], selected were separated into analyses. reporting discharge 30 days, 3 months 6 months. Both meta-analyses risk ratio favor 95% confidence interval crossed 1, results group analyses considered statistically significant. Splitting evaluation time points reduced eligible subsequently overall power meta-analysis, ability demonstrate positive effect. summarizing available underlying question. Why split underpowered clear. addition, previously shown, proportion good/poor does change [17], thus splitting required, performing provide results. A retrospective demonstrated subgroup suspected moderate benefited most therapy 34°C. These specifically patient lower basic support [15], no-flow [16], intermediate [18], lactate levels arrival [19], classification [20,21], EEG pattern suggesting encephalopathy [22]. total, represent 40% All make pathophysiological sense, since neuroprotective too mild, or, side range, severe. Cochrane systematic review recently [23]. Due methodology, standardization, transparency, highest quality [24]. represents recent complete includes 12 trials. authors found, conventional methods induce therapeutic associated seemed non-witnessed CPR rates 60%, times minute, within released Cochran submitted editorial process [25]. However, stated pending formal assessment, seems including [26] would changed main conclusion Another confirms [27]. After publication very review, another update served basis [28]. concluded updated although intervals cannot rule out additional RCTs, mentioned above. Summary 2023 Animal models remarkable induced Some significant though controlled do confirm Which (32 34°C) temperatures still unknown. Earlier non-significant 34° arrest. comprehensive RCT, Several indicate especially presumable damage. human worse outcome. Recommendation uncertainty exists whether terms improving ESICM merely prevent fever, our view, neither take account evidence, nor consider shortcomings studies. Based significantly along fact deleterious outcome, we suggest international follow interim period clinicians should adult soon feasible, maintain least h. Active (36.5 37.7°C) ensured rewarming before during neuroprognostication avoid fever. Future needed identify who find optimal point initiating hypothermia. Acknowledgements Conflicts interest Wilhelm Behringer: Speakers honoraria Zoll Medical Corporation Becton Dickinson GmbH. Bernd W. Böttiger: fees Forum für medizinische Fortbildung (FomF), Baxalta Deutschland GmbH, ZOLL C.R. Bard GS Elektromedizinische Geräte G. Stemple Novartis Pharma Philips GmbH Market DACH, Bioscience Valuation BSV Fundacja Polski Instytut Evidence Medicine. Daniele Biasucci: Honoraria Vygon SAS having written educational materials website. Jim Connolly: Educational Sonosite; ultrasound machine placement Terrason, Cannon, Echonous; Personal shares Smith & Nephew, GSK, Inovio, Linde, any conflicts related topic manuscript. Abdo Khoury: Corporation, Archeon Medical, Aguettant, Vygon, Baxter, Fisher Paykel, Giuseppe Ristagno: Participated advisory board Healthcare remaining authors, interest.
Язык: Английский
