Variability in temperature control practices amongst the Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial.

AIM: Temperature control is a complex bundled intervention; the synergistic impact of each individual component is ill defined and underreported. Resultantly, the influence of parameter optimization on temperature control's overall neuroprotective effect remains poorly understood. To characterize variability in temperature control parameters and barriers to short pre-induction and induction times, we surveyed sites enrolling in an ongoing multicenter clinical trial. METHODS: This was a cross-sectional, survey study evaluating temperature control practices within the Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). A 23-question web-based survey (Qualtrics) was distributed to the site principal investigators by email. Respondents were asked about site practices pertaining to the use of temperature control, including the request to upload individual institutional protocols. Open-ended responses were analyzed qualitatively by categorizing responses into identified themes. To complement survey level data, records pertaining to the quality of temperature control were extracted from the ICECAP trial database. RESULTS: The survey response rate was 75% (n = 51) including 23.5% (n = 12) survey respondents who uploaded institutional protocols. Most sites reported having institutional protocols for temperature control (n = 41; 80%), including 62.5% (n = 32) who had separate protocols for initiation of temperature control in the emergency department (ED). Fewer sites had protocols specific to sedation or neuromuscular blockade (NMB) management (n = 35, 68.6%). Use of NMB during temperature control induction was variable; 61.7% (n = 29) of sites induced paralysis less than 20% of the time. While most institutional protocols (n = 11, 83.3%) commented on the importance of early initiation of temperature control, this was incongruent with the largest reported barrier, which was clinical nihilism regarding the importance of early temperature control initiation (n = 30, 62.5%). Within the ICECAP trial database, 1 in 2 patients were treated with NMB however, use of NMB and time to initiation of temperature control device varied widely between sites. CONCLUSION: Amongst ICECAP trial sites, there was significant variability in resources, methods, and barriers for early temperature control initiation. Defining and standardizing high-quality temperature control must be prioritized, as it may impact the interpretation of past and current clinical trial findings.

Factors predicting mortality in the cardiac ICU during the early phase of targeted temperature management in the treatment of post-cardiac arrest syndrome - The RAPID score.

Introduction: Survival rates after out-of-hospital cardiac arrest (OHCA) remain low, and early prognostication is challenging. While numerous intensive care unit scoring systems exist, their utility in the early hours following hospital admission, specifically in the targeted temperature management (TTM) population, is questionable. Our aim was to create a score system that may accurately estimate outcome within the first 12 h after admission in patients receiving TTM. Methods: We analyzed data from 103 OHCA patients who subsequently underwent TTM between 2016 and 2022. Patient demographic data, prehospital characteristics, clinical and laboratory parameters were already available in the first 12 h after admission were collected. Following a bootstrap-based predictor selection, we constructed a nonlinear logistic regression model. Internal validation was performed using bootstrap resampling. Discrimination was described using the c-statistic, whereas calibration was characterized by the intercept and slope. Results: According to the Akaike Information Criterion (AIC) heart rate (AIC = 9.24, p = 0.0013), age (AIC = 4.39, p = 0.0115), pH (AIC = 3.68, p = 0.0171), initial rhythm (AIC = 4.76, p = 0.0093) and right ventricular end-diastolic diameter (AIC = 2.49, p = 0.0342) were associated with 30-day mortality and were used to build our predictive model and nomogram. The area under the receiver-operating characteristics curve for the model was 0.84. The model achieved a C-statistic of 0.7974, with internally validated acceptable calibration (intercept: -0.0190, slope: 0.7772) and low error rates (mean absolute error: 0.040). Conclusion: The model we have developed may be suitable for early risk assessment of patients receiving TTM as part of primary post-resuscitation care. The calculator needed for scoring can be accessed at the following link: https://www.rapidscore.eu/.

Association Between the Rewarming Duration and Neurological Outcomes after Extracorporeal Cardiopulmonary Resuscitation Followed by Targeted Temperature Management for Out-of-Hospital Cardiac Arrests: A Secondary Analysis of the SAVE-J II Study.

There are no studies examining the association between rewarming durations and neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) followed by targeted temperature management (TTM) for patients with out-of-hospital cardiac arrest (OHCA). This study aimed to examine the association between rewarming durations and neurological outcomes after ECPR with TTM for patients with OHCA. This was a secondary analysis of the Advanced Life Support Study Registry for Ventricular Fibrillation with Extracorporeal Circulation in Japan study, a retrospective, multicenter study. Patients with OHCA who underwent ECPR and completed a TTM of 34°C and <34°C were included. Favorable neurological outcomes (cerebral performance categories 1-2) and survival upon hospital discharge were the primary outcomes. In total, 407 patients were included, with favorable neurological outcomes upon hospital discharge in 106 patients. The numbers of patients with rewarming durations of <24 hours, 24 hours, and >24 hours were 178, 133, and 96, respectively. In the multivariable analysis, a rewarming duration of <24 hours was not significantly associated with favorable neurological outcomes [odds ratio (OR): 1.06, 95% confidence interval (CI): 0.60-1.87, p = 0.84] or survival (OR: 0.96, 95% CI: 0.58-1.57, p = 0.86) compared with that of 24 hours, and that of <24 hours was not significantly associated with favorable neurological outcomes (OR: 0.74, 95% CI: 0.40-1.71, p = 0.56) or survival (OR: 0.74, 95% CI: 0.42-1.28, p = 0.38) than that of >24 hours. A rewarming duration of <24 hours in TTM after ECPR for OHCA was not significantly associated with favorable neurological outcomes or survival than that of 24 hours or >24 hours.

Impact of Time to Initiation of Targeted Temperature Management Among Patients with Out-of-Hospital Cardiac Arrest Undergoing Percutaneous Coronary Intervention.

Delays in initiation of targeted temperature management (TTM) have been observed in randomized trials evaluating immediate or delayed coronary angiography among survivors of ventricular tachycardia (VT) or ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA), but whether delays are associated with adverse clinical outcomes is unknown. Resuscitated survivors of VT/VF OHCA who received TTM between April 2011 and June 2015 were identified and time to TTM initiation was described. The association between TTM initiation <2 versus ≥2 hours, neurologically favorable, and overall survival to hospital discharge was assessed. In a propensity-weighted analysis of 2954 patients, a significantly larger proportion of patients undergoing percutaneous coronary intervention (PCI) had TTM initiation ≥2 hours (48.6%) as compared to patients undergoing angiography (41.4%) or those who did not undergo a procedure (33.0%; p < 0.001 for all comparisons). In this cohort, the odds of neurologically favorable survival (odds ratios [OR]: 0.88, 95% confidence intervals [CI] = 0.75-1.02) and overall survival (OR: 0.92, 95% CI = 0.83-1.03) to hospital discharge were similar among ST-elevation myocardial infarction (STEMI) patients who underwent PCI with TTM initiation <2 versus ≥2 hours. Patients without STEMI who underwent PCI with TTM initiation ≥2 hours and did not have a "do not resuscitate" order or withdrawal of life-sustaining care had decreased odds of neurologically favorable survival to hospital discharge (OR: 0.45, 95% CI = 0.22-0.93) compared to TTM initiation <2 hours. PCI was associated with delays in TTM initiation ≥2 hours among resuscitated survivors of VT/VF OHCA. Delays in TTM initiation ≥2 hours were associated with decreased odds of neurologically favorable survival among patients without STEMI who underwent PCI.

Navigating the 'Triangle of Death': A Multidisciplinary Approach in Severe Multi-Trauma Management.

This case report details the challenging management of a 45-year-old male construction worker who suffered severe multiple injuries after a fall and subsequent collision with cement mixers. The patient presented with extensive injuries, including amputation, fractures and internal bleeding, leading to a state known as the 'triangle of death'. Despite the initial grim prognosis, evidenced by an ISS score of 28 and a mortality risk coefficient of 89.56%, the patient was successfully resuscitated and managed through a multidisciplinary approach. This included damage control resuscitation, emergency vascular interventions and targeted temperature management for brain protection. The patient's recovery highlights the effectiveness of comprehensive trauma management and the critical role of coordinated care in severe multi-trauma cases.

Practice survey on recent changes in post cardiac arrest care and temperature management in French intensive care units.

BACKGROUND: Recent guidelines for post-cardiac arrest (CA) management have undergone significant changes regarding targeted therapeutic management (TTM), transitioning from hypothermia to temperature control. We aimed to assess changes in post-CA management in French intensive care units following the new recommendations. METHODS: Two declarative web surveys were conducted from March to August 2023. We compared the doctors' survey to that previously published in 2015. We contacted 389 departments from 276 French centers. RESULTS: Three hundred thirty-four physicians from 189 distinct ICUs departments participated in the survey. TTM was used by 95.5 % of respondents. TTM with temperature feedback device was used by 64 % of respondents. In multivariate analysis, use of TTM with temperature feedback was associated with university hospital responder [OR 1.99 (1.19-3.34, p = 0.009)], high CA admissions rate [OR 2.25 (1.13-4.78, p = 0.026)], use of a written CA procedure [OR 1.76 (1.07-2.92, p = 0.027)] and presence of a cath-lab performing coronary angiography [OR 2.42 (1.33-4.44, p = 0.004)]. The targeted temperature rose from 32 to 34 °C in 2015, to 35-36 °C in 2023 (p < 0.001). Proportions of TTM with temperature feedback devices switched from 45 % to 65 % (p < 0.001). 660 nurses responses from 150 ICUs were analyzed. According to TTM users, gel-coated water circulating pads and intravascular cooling were considered the most effective devices and were found to be easily adjustable. CONCLUSIONS: These surveys provide insights into post-resuscitation care and TTM practice in France. One year after their publication, the latest recommendations concerning TTM have not been fully implemented, as the majority of ICUs continue to use moderate hypothermia. They widely reported employing specific TTM, with the use of TTM with temperature feedback devices increasing significantly. Heterogeneity exists regarding the TTM systems used, with a significant proportion lacking temperature feedback. This aspect requires specific attention, depending on local constraints and devices costs.

The compliance with TTM protocol may benefit outcomes in cardiac arrest survivors: A retrospective cohort study.

BACKGROUND: Established protocols for implementing high-quality targeted temperature management (TTM) provide guidance concerning the cooling rate, duration of maintenance, and rewarming speed. However, whether compliant to TTM protocols results in improved survival and better neurological recovery has not been examined. METHODS: A retrospective cohort study enrolled 1141 survivors of non-traumatic adult cardiac arrest with a pre-arrest cerebral performance category (CPC) score of 1-2 from 2015 to 2020 at a tertiary medical center. Of the survivors, 330 patients who underwent TTM were further included. Patients with spontaneous hypothermia (<35 °C) (n = 107) and expired during the TTM (n = 21) were excluded. A total of 202 patients were thus enrolled. One hundred and ten patients underwent TTM that completely complied with the protocol (protocol-complaint group), but 92 patients deviated in some manner from the protocol (protocol non-compliant group). RESULTS: Fifty patients (50%) and 46 patients (50%) in the protocol-compliant and non-compliant groups, respectively, did not survive to hospital discharge. In the protocol-compliant group, 42 patients (38.2%) had favorable neurological recovery, compared with 32 patients (34.8%) in the protocol non-compliant group. After adjusting for age, initial shockable rhythm, witnessed collapse, and cardiopulmonary resuscitation duration, protocol non-compliant was associated with the poor neurological outcomes (aOR 2.44, 95% CI = 1.13-5.25), but not with in-hospital mortality (aOR 1.31, 95% CI = 0.70-2.47). The most common reason for noncompliance was a prolonged duration reaching the target temperature (n = 33, 58.7%). The number of phases of non-compliant was not significantly associated with in-hospital mortality or poor neurological recovery. CONCLUSION: Among cardiac arrest survivors undergoing TTM, those who did not receive TTM that in compliance with the protocol were more likely to experience poor neurological recovery than those whose TTM fully complied with the protocols. The most frequently identified deviation was a prolonged duration to reaching the target temperature.

Cerebrospinal Creatine Kinase BB Isoenzyme: A Biomarker for Predicting Outcome After Cardiac Arrest.

BACKGROUND: Cerebrospinal fluid creatine kinase BB isoenzyme (CSF CK-BB) after cardiac arrest (CA) has been shown to have a high positive predictive value for poor neurological outcome, but it has not been evaluated in the setting of targeted temperature management (TTM) and modern CA care. We aimed to evaluate CSF CK-BB as a prognostic biomarker after CA. METHODS: We performed a retrospective cohort study of patients with CA admitted between 2010 and 2020 to a three-hospital health system who remained comatose and had CSF CK-BB assayed between 36 and 84 h after CA. We examined the proportion of patients at hospital discharge who achieved favorable or intermediate neurological outcome, defined as Cerebral Performance Category score of 1-3, compared with those with poor outcome (Cerebral Performance Category score 4-5) for various CSF CK-BB thresholds. We also evaluated additive value of bilateral absence of somatosensory evoked potentials (SSEPs). RESULTS: Among 214 eligible patients, the mean age was 54.7 ± 4.8 years, 72% of patients were male, 33% were nonwhite, 17% had shockable rhythm, 90% were out-of-hospital CA, and 83% received TTM. A total of 19 (9%) awakened. CSF CK-BB ≥ 230 U/L predicted a poor outcome at hospital discharge, with a specificity of 100% (95% confidence interval [CI] 82-100%) and sensitivity of 69% (95% CI 62-76%). When combined with bilaterally absent N20 response on SSEP, specificity remained 100% while sensitivity increased to 80% (95% CI 73-85%). Discordant CK-BB and SSEP findings were seen in 13 (9%) patients. CONCLUSIONS: Cerebrospinal fluid creatine kinase BB isoenzyme levels accurately predicted poor neurological outcome among CA survivors treated with TTM. The CSF CK-BB cutoff of 230 U/L optimizes sensitivity to 69% while maintaining a specificity of 100%. CSF CK-BB could be a useful addition to multimodal neurological prognostication after CA.

Neuroprotective Effects of Inhaled Xenon Gas on Brain Structural Gray Matter Changes After Out-of-Hospital Cardiac Arrest Evaluated by Morphometric Analysis: A Substudy of the Randomized Xe-Hypotheca Trial.

BACKGROUND: We have earlier reported that inhaled xenon combined with hypothermia attenuates brain white matter injury in comatose survivors of out-of-hospital cardiac arrest (OHCA). A predefined secondary objective was to assess the effect of inhaled xenon on the structural changes in gray matter in comatose survivors after OHCA. METHODS: Patients were randomly assigned to receive either inhaled xenon combined with target temperature management (33 °C) for 24 h (n = 55, xenon group) or target temperature management alone (n = 55, control group). A change of brain gray matter volume was assessed with a voxel-based morphometry evaluation of high-resolution structural brain magnetic resonance imaging (MRI) data with Statistical Parametric Mapping. Patients were scheduled to undergo the first MRI between 36 and 52 h and a second MRI 10 days after OHCA. RESULTS: Of the 110 randomly assigned patients in the Xe-Hypotheca trial, 66 patients completed both MRI scans. After all imaging-based exclusions, 21 patients in the control group and 24 patients in the xenon group had both scan 1 and scan 2 available for analyses with scans that fulfilled the quality criteria. Compared with the xenon group, the control group had a significant decrease in brain gray matter volume in several clusters in the second scan compared with the first. In a between-group analysis, significant reductions were found in the right amygdala/entorhinal cortex (p = 0.025), left amygdala (p = 0.043), left middle temporal gyrus (p = 0.042), left inferior temporal gyrus (p = 0.008), left parahippocampal gyrus (p = 0.042), left temporal pole (p = 0.042), and left cerebellar cortex (p = 0.005). In the remaining gray matter areas, there were no significant changes between the groups. CONCLUSIONS: In comatose survivors of OHCA, inhaled xenon combined with targeted temperature management preserved gray matter better than hypothermia alone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT00879892.

Technical note: Computational study on thermal management schemes for tumor-treating fields therapy.

BACKGROUND: The study focuses on thermal management in tumor-treating fields (TTFields) therapy, crucial for patient compliance and therapeutic effectiveness. TTFields therapy, an established treatment for glioblastoma, involves applying alternating electric fields to the brain. However, managing the thermal effects generated by electrodes is a major challenge, impacting patient comfort and treatment efficiency. PURPOSE: This research aims to explore methods for controlling temperature increases during TTFields therapy without reducing its duty cycle. The study emphasizes optimizing electrode configurations and array arrangements to mitigate temperature rise, thereby maintaining therapy effectiveness and patient compliance. METHODS: Using a simplified multi-layer tissue model and finite element analysis, various electrode configurations and array shapes were tested in COMSOL Multiphysics v6.0. Adjustments included changing the electrode gel layer radius from 8 to 12 mm, electrode spacing, and transitioning to a more uniform array arrangement, such as a square array or a circular array. RESULTS: The study revealed a strong correlation between high temperatures and edge current density distributions on electrodes. It was found that increasing the electrode gel layer's diameter, enlarging electrode spacing, and adopting a uniform array arrangement markedly mitigated temperature rises. By increasing the gel layer radius from the original 10 to 12 mm, a reduction in the peak temperature increases of approximately 0.3°C was observed. Changing the layout from rectangular to circular with the same area further reduced the peak temperature rise by 0.5°C. Additionally, enlarging the spacing between electrodes also contributed to temperature control. By integrating these strategies, we designed a new circular electrode array with an electrode spacing of 45 mm and a gel radius of 12 mm, successfully reducing the peak temperature from 42.1°C to 40.8°C, effectively achieving temperature control. CONCLUSIONS: The research demonstrates that improving electrode and array configurations can effectively manage temperature in TTFields therapy without compromising treatment duration. This strategy is crucial as TTFields therapy relies on prolonged field exposure for effectiveness. The findings offer valuable insights into thermal management in electrode array design and could lead to enhanced patient compliance and treatment efficacy in TTFields therapy.

The Relationship between the Ratio of Urine Osmolality to Serum Osmolality and Neurological Outcomes in Out-of-hospital Cardiac Arrest Patients.

Background: Progressive ischemic brain injury after cardiac arrest can cause damage to the hypothalamic-pituitary axis, particularly the pituitary gland. This may impact serum osmolality (SOsm) and urine osmolality (UOsm) in patients who have experienced out-of-hospital cardiac arrest (OHCA). We assumed that a low ratio of UOsm to SOsm (USR) is related to poor outcomes among OHCA patients. Therefore, the present study was designed to evaluate the association between the USR within 72 h after the restoration of spontaneous circulation (ROSC) and 6-month neurological outcomes in OHCA patients. Methods: This prospective, observational study included OHCA patients with targeted temperature management at Chonnam National University Hospital in Gwangju, Korea, between January 2016 and December 2022. We collected SOsm and UOsm data at admission (T0) and 24 (T1), 48 (T2), and 72 h (T3) after ROSC. The primary outcome was a poor neurological outcome at 6 months defined by cerebral performance categories 3, 4, or 5. Results: This study included 319 patients. The mean UOsm and USRs at T0, T1, T2, and T3 of patients with poor outcomes were lower than those of patients with good outcomes. Multivariable analysis indicated that the USRs at T1 (odds ratio [OR], 0.363; 95% confidence interval [CI], 0.221-0.594), T2 (OR, 0.451; 95% CI, 0.268-0.761), and T3 (OR, 0.559; 95% CI, 0.357-0.875) were associated with a poor outcome. The areas under the receiver operating characteristic curves of USRs at T0, T1, T2, and T3 for predicting poor outcomes were 0.615 (95% CI, 0.559-0.669), 0.711 (95% CI, 0.658-0.760), 0.724 (95% CI, 0.671-0.772), and 0.751 (95% CI, 0.699-0.797), respectively. Conclusions: The USRs within 72 h of ROSC were associated with poor neurological outcomes at 6 months in OHCA patients.

N6-cyclohexyladenosine is better than meperidine and buspirone at suppressing metabolism during TTM32 but does not improve outcome after cardiac arrest.

N6-clyclohexyladenosine (CHA) is an adenosine A1 receptor agonist that inhibits thermogenesis. Cardiovascular side effects however, limit use of CHA as a therapeutic. We and others have shown that this can be reversed by administering 8-p-(sulfophenyl)theophylline (8-SPT), a nonspecific antagonist that does not cross the BBB. Other evidence shows that CNS actions of CHA may contribute to bradycardia through enhanced vagal tone and other mechanisms. Here we test the hypothesis that 8-SPT pretreatment alone is sufficient to prevent hypotension caused by CHA. To test this hypothesis, we pretreated rats with 8-SPT alone, and in combination with other antagonists to test the hypothesis that direct action of CHA on the heart is the primary mechanism by which CHA induces bradycardia and hypotension. Results show that pretreatment with 8-SPT alone is not sufficient to prevent CHA-induced hypotension. Pretreatment with 8-SPT or atropine alone did not prevent the fall in mean arterial pressure (MAP) and heart rate (HR), however, pretreatment with 8-SPT (25 mg/kg) and atropine (1 mg/kg) 15 min before CHA (1 mg/kg) preserves MAP and HR baseline values after CHA administration. We next asked if blood pressure was managed during the transition into a hypometabolic state, would prolong CHA-mediated inhibition of metabolism after cardiac arrest improve outcome better than anti-shivering medications meperidine and buspirone. We found that CHA-mediated hypotension can be mitigated by pretreatment with atropine and 8-SPT. This combination administered after cardiac arrest facilitated temperature management and metabolic suppression better than meperidine and buspirone, however, did not improve survival.

Advanced age and neurological recovery in elderly patients with out-of-hospital cardiac arrest treated with targeted temperature management: a nationwide population­based registry study 2016-2020.

The likelihood of neurological recovery after out-of-hospital cardiac arrest (OHCA) may be influenced by advanced age. This study aims to evaluate the impact of advanced age on neurological recovery in elderly OHCA survivors treated with targeted temperature management (TTM). This retrospective observational study, using a nationwide population-based OHCA registry, was conducted from January 2016 to December 2020. Non-traumatic elderly (≥ 65 years) comatose OHCA survivors treated with TTM were categorized according to age (65-69, 70-74, 75-79, and ≥ 80 years). Among 23,336 admitted OHCA patients, 3,398 were treated with TTM. Excluding 2,033 non-elderly patients, 1,365 were analyzed. Among the four groups, the rate of good neurological outcomes decreased by advanced age (24.2%, 16.1%, 11.4%, and 5.9%, respectively), which was also observed after subgroup analysis based on the initial shockable (40.6%, 31.5%, 28.6%, and 14.9%, respectively) and non-shockable rhythm (10.6%, 7.2%, 4.1%, and 3.4%, respectively). Multivariate analysis showed the adjusted odds ratio (aOR) for good neurological outcome decreased as age increased (65-69: reference, 70-74: aOR 0.70, 75-79: aOR 0.49, and ≥ 80 years: aOR 0.25). The optimal age cutoffs for good outcomes in elderly OHCA survivors with shockable and non-shockable rhythm were 77 and 72 years, respectively. The neurologic recovery rate in OHCA survivors treated with TTM gradually decreased with increasing age. However, even patients aged ≥ 80 years with shockable rhythm had a good neurologic outcome of 14.9% compared with patients aged 65-69 years with non-shockable rhythm (10.6%).

Beyond Control: Temperature Burden in Patients with Spontaneous Subarachnoid Hemorrhage-An Observational Study.

BACKGROUND: Temperature abnormalities are common after spontaneous subarachnoid hemorrhage (SAH). Here, we aimed to describe the evolution of temperature burden despite temperature control and to assess its impact on outcome parameters. METHODS: This retrospective observational study of prospectively collected data included 375 consecutive patients with SAH admitted to the neurological intensive care unit between 2010 and 2022. Daily fever (defined as the area over the curve above 37.9 °C multiplied by hours with fever) and spontaneous hypothermia burden (< 36.0 °C) were calculated over the study period of 16 days. Generalized estimating equations were used to calculate risk factors for increased temperature burdens and the impact of temperature burden on outcome parameters after correction for predefined variables. RESULTS: Patients had a median age of 58 years (interquartile range 49-68) and presented with a median Hunt & Hess score of 3 (interquartile range 2-5) on admission. Fever (temperature > 37.9 °C) was diagnosed in 283 of 375 (76%) patients during 14% of the monitored time. The average daily fever burden peaked between days 5 and 10 after admission. Higher Hunt & Hess score (p = 0.014), older age (p = 0.033), and pneumonia (p = 0.022) were independent factors associated with delayed fever burden between days 5 and 10. Increased fever burden was independently associated with poor 3-month functional outcome (modified Rankin Scale 3-6, p = 0.027), poor 12-month functional outcome (p = 0.020), and in-hospital mortality (p = 0.045), but not with the development of delayed cerebral ischemia (p = 0.660) or intensive care unit length of stay (p = 0.573). Spontaneous hypothermia was evident in the first three days in patients with a higher Hunt & Hess score (p < 0.001) and intraventricular hemorrhage (p = 0.047). Spontaneous hypothermia burden was not associated with poor 3-month outcome (p = 0.271). CONCLUSIONS: Early hypothermia was followed by fever after SAH. Increased fever time burden was associated with poor functional outcome after SAH and could be considered for neuroprognostication.

The Effectiveness of Target Temperature Management on Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

The effectiveness of target temperature management (TTM) in poor-grade aneurysmal subarachnoid hemorrhage (aSAH) remains a topic of debate. In order to assess the clinical efficacy of TTM in patients with poor-grade aSAH, we conducted a systematic review and meta-analysis. This research was registered in PROSPERO (CRD42023445582) and included all relevant publications up until October 2023. We compared the TTM groups with the control groups in terms of unfavorable outcomes (modified Rankin scale [mRS] score > 3), mortality, delayed cerebral ischemia (DCI), cerebral vasospasm (CVS), and specific complications. Subgroup analyses were performed based on country, study type, follow-up time, TTM method, cooling maintenance period, and rewarming rate. Effect sizes were calculated as relative risk (RR) using random-effect or fixed-effect models. The quality of the articles was assessed using the methodological index for non-randomized studies scale. Our analysis included a total of 5 clinical studies (including 1 randomized controlled trial) and 219 patients (85 in the TTM group and 134 in the control group). Most of the studies were of moderate quality. TTM was found to be associated with a statistically significant improvement in mortality (mRS score 6) rates compared with the control group (RR = 0.61, 95% confidence interval [CI]: 0.40-0.94, p = 0.026). However, there was no statistically significant difference in unfavorable outcomes (mRS 4-6) between the TTM and control groups (RR = 0.94, 95% CI: 0.71-1.26, p = 0.702). The incidence of adverse events, including DCI, CVS, pneumonia, cardiac complications, and electrolyte imbalance, did not significantly differ between the two groups. In conclusion, our overall results suggest that TTM does not significantly reduce unfavorable outcomes in poor-grade aSAH patients. However, TTM may decrease mortality rates. Preoperative TTM may cause patients to miss the opportunity for surgery, although it temporarily protects the brain. Furthermore, the incidence of adverse events was similar between the TTM and control groups.

Neuromuscular blocking agents during targeted temperature management for out-of-hospital cardiac arrest patients.

BACKGROUND: Neuromuscular blocking agents (NMBAs) can control shivering during targeted temperature management (TTM) of patients with cardiac arrest. However, the effectiveness of NMBA use during TTM on neurologic outcomes remains unclear. We aimed to evaluate the association between NMBA use during TTM and favorable neurologic outcomes after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: A multicenter, prospective, observational cohort study from 2019 to 2021. It included OHCA patients who received TTM after hospitalization. We conducted overlap weight propensity-score analyses after multiple imputation to evaluate the effect of NMBAs during TTM. The primary outcome was a favorable neurological outcome, defined as a cerebral performance category of 1 or 2 at discharge. Subgroup analyses were conducted based on initial monitored rhythm and brain computed tomography findings. RESULTS: Of the 516 eligible patients, 337 received NMBAs during TTM. In crude analysis, the proportion of patients with favorable neurological outcome was significantly higher in the NMBA group (38.3% vs. 16.8%; risk difference (RD): 21.5%; 95% confidence interval (CI): 14.0% to 29.1%). In weighted analysis, a significantly higher proportion of patients in the NMBA group had a favorable neurological outcome compared to the non-NMBA group (32.7% vs. 20.9%; RD: 11.8%; 95% CI: 1.2% to 22.3%). In the subgroup with an initial shockable rhythm and no hypoxic encephalopathy, the NMBA group showed significantly higher proportions of favorable neurological outcomes. CONCLUSIONS: The use of NMBAs during TTM was significantly associated with favorable neurologic outcomes at discharge for OHCA patients. NMBAs may have benefits in selected patients with initial shockable rhythm and without poor prognostic computed tomography findings.

Treatment strategies for patients with out-of-hospital cardiac arrest associated with traumatic brain injury: A case series.

INTRODUCTION: Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. METHODS: We analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS: Of the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49-70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. CONCLUSION: Delayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration.

Association of temperature management strategy with fever in critically ill children after out-of-hospital cardiac arrest.

Objective: To determine whether ICU temperature management strategy is associated with fever in children with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). Methods: We conducted a single-center retrospective cohort study at a quaternary Children's hospital between 1/1/2016-31/12/2020. Mechanically ventilated children (<18 y/o) admitted to Pediatric or Cardiac ICU (PICU/CICU) with ROSC after OHCA who survived at least 72 h were included. Primary exposure was initial PICU/CICU temperature management strategy of: (1) passive management; or (2) warming with an air-warming blanket; or (3) targeted temperature management with a heating/cooling (homeothermic) blanket. Primary outcome was fever (≥38°C) within 72 h of admission. Results: Over the study period, 111 children with ROSC after OHCA were admitted to PICU/CICU, received mechanical ventilation and survived at least 72 h. Median age was 31 (IQR 6-135) months, 64% (71/111) were male, and 49% (54/111) were previously healthy. Fever within 72 h of admission occurred in 51% (57/111) of patients. The choice of initial temperature management strategy was associated with occurrence of fever (χ2 = 9.36, df = 2, p = 0.009). Fever occurred in 60% (43/72) of patients managed passively, 45% (13/29) of patients managed with the air-warming blanket and 10% (1/10) of patients managed with the homeothermic blanket. Compared to passive management, use of homeothermic, but not of air-warming, blanket reduced fever risk [homeothermic: Risk Ratio (RR) = 0.17, 95%CI 0.03-0.69; air-warming: RR = 0.75, 95%CI 0.46-1.12]. To prevent fever in one child using a homeothermic blanket, number needed to treat (NNT) = 2. Conclusion: In critically ill children with ROSC after OHCA, ICU temperature management strategy is associated with fever. Use of a heating/cooling blanket with homeothermic feedback reduces fever incidence during post-arrest care.

Review of Temperature Management in Traumatic Brain Injuries.

Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.