Hypothermia After Cardiac Arrest:

Where Are We Now?

David A. Pearson, MD, MS

Associate Professor

Director of Cardiac Arrest Resuscitation

Carolinas HealthCare System

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Disclosures

I have no financial

interest,

arrangement, or

affiliations and no

commercial

interests, ties, or

grants related to

material covered in

this lecture.

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Objectives

• Institute of Medicine (IOM) Report & AHA 2015 Updates

• Targeted temperature management

• Regionalization & Systems of care: Code Cool

8 Ways To Improve Survival:

1. Establish a national cardiac arrest registry.

2. Foster a culture of action through public awareness and training.

3. Enhance the capabilities and performance of EMS systems.

4. Set national accreditation standards related to cardiac arrest for

hospitals and health care systems.

5. Adopt continuous quality improvement programs.

6. Accelerate research on pathophysiology, new therapies, and

translation of science for cardiac arrest.

7. Accelerate research on evaluation & adoption of CA therapies.

8. Create a national cardiac arrest collaborative.

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AHA 2015: IHCA & OHCA Chains of Survival

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6 Safar P, 1961.

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Pre-Hospital Cooling

AHA 2015: Pre-hospital Cooling

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• 1359 patients (583 with VF, 776 without VF)

• Decreased core temp by 1.20°C & 1.30°C

• No difference in survival or neurological status

• Re-arrest in field, pulmonary edema, diuretic use

higher w/ cold IVF (26% vs 21%, p=.008) Kim et al. JAMA 2013.

Pre-hospital Cooling: North Carolina

• 847 patients in 2012

• 55% received pre-hospital hypothermia

• Pre-hospital initiation of hypothermia: OR 1.55

• Improved neuro outcome @ discharge: OR 1.56

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Rao MP et al. Prehosp Emerg Care. 2016

Intra-Arrest Cooling

• Trans-nasal evaporative cooling, ice packs, cold IVF

• Improves defibrillation success?

• Mortality & neurological outcome?

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TARGETED TEMPERATURE

MANAGEMENT

AHA 2015 Guidelines:

Targeted Temperature Management

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Landmark Trials

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Europe

• RCT n=275, 9 centers

• OOH witnessed VT/VF

• ROSC < 60min

• No purposeful response

• MAP > 80 mmHg

• 24 hr cooling to 32-34C

Australia

• RCT n=77, 4 centers

• OOH witnessed VF

• ROSC

• GCS < 7

• Pre-hospital cooling

• 12 hr cooling to 33C

HACA Study Group. NEJM 2002. Bernard SA, et al. NEJM 2002.

Landmark Trials

Survival with Good Neuro Outcome

• 939 comatose out-of-hospital cardiac arrest patients

• Randomly assigned: 33°C vs 36°C

• Outcomes:

– All-cause mortality

– Poor neurological function at 180 days

Nielsen et al. NEJM. 2013.

Survival with Good Neuro Outcome

0%

10%

20%

30%

40%

50%

60%

HACA Australian TTM

33°C

Not 33°C

• 950 unconscious adults 939 included

• Mini-Mental State Examination (MMSE)

• MMSE 6 months after cardiac arrest

• No difference with 33C vs 36C

• 66.5% at 33C vs 61.8% at 36C (p=0.32) with complete

mental recovery

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• 26,183 patients: Mar 2002 – Dec 2014

• 1568 (6%) treated with therapeutic hypothermia

• TH associated with LOWER in-hospital survival

(27.4% vs 29.2%; 95% CI: 0.80 to 0.97)

• TH associated with LOWER favorable neuro survival

(17.0% vs 20.5%; 95% CI: 0.69 to 0.90)

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Cool Questions

• Optimal time to initiate cooling?

• Optimal method of cooling?

• Optimal rate of cooling?

• Optimal temperature?

• Optimal duration?

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AHA 2015 Guidelines

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AHA 2015 Guidelines

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Minneapolis Experience

• 140 out-of-hospital cardiac arrest patients

• ROSC < 60 minutes

• Included: any initial rhythm, HD instability, STEMI

• Excluded: DNR, active bleeding, comatose before arrest

• 51% good neurological outcome

Mooney, et al. Circulation. 2011.

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CMC Experience

• Local: 46% good neurological outcome

• Referred: 39% good neurological outcome

Heffner, et al. AHJ. 2012.

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Japanese Experience

• Second link (early defibrillation) most important

• Fifth link (multidisciplinary post-resuscitation care in a

regional center) next most important

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AHA-Recommended Hospital Designation

Level I Center:

Cardiac Resuscitation

Center

• Hypothermia

• PCI

• Critical care

• AICD assessment &

placement

Level II Center:

Cardiac Resuscitation

Center

• Resuscitate

• Initiate cooling

• Transfer

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TTM - Stages

1. Induction

– Infuse 30 mL/kg 4◦C NS IV rapid bolus

• Typically 2500 mL

– 15 ice packs to axilla, groin, neck, torso

– Administer paralytic IV push

– Initiate device (surface or internal)

2. Maintenance

– Achieve goal temperature of 33◦C

– 36◦C for relative contraindications or cooling intolerance

– Maintain for 24 hours

3. Rewarming

– Controlled: < 0.5°C/hour

4. Controlled normothermia

Induction Maintenance

• Surface (noninvasive)

• Medivance® (now Bard Medical)

• Arctic Sun® 2000, 5000

• Internal (invasive)

• Zoll IVTM™ catheter

• Quattro®, Icy®, Cool Line®

20%

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

2007 2008 2009 2010 2011 2012 2013 Jan - June2014

Code Cool Neurologic Outcome for Witnessed, Shockable

Arrest Patients 2013/2014 Performance with 2015 Baseline and Target*

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Baseline: 50.7%

Target: 53.2%

*Includes all patients activated as “code cool” through the Physician Connection Line

*Good neurologic outcome is defined as a CPC score of “1” or “2”

Stretch: 55.8%

Good Neuro Outcome: Witnessed

Shockable Arrests

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Final Thoughts

• Pre-hospital Cooling

• Out-of-hospital Cardiac Arrest – Cooling

• In-hospital Cardiac Arrest – Cooling

• Regionalization

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Questions?