HEDEFE YÖNELİK SICAKLIK YÖNETİMİYLE İYİLEŞTİRİLMİŞ SONUÇLAR (HSY): POST-KARDİYAK ARREST HASTALARDA KLİNİK ÖNEMİ

Year 2022, Volume: 1 Issue: 3, 119 - 138, 29.12.2022

Pelin Karaaslan , Cem Erdoğan , Deniz Kızılaslan Burcu Tunay , Yunus Oktay Atalay , Hüseyin Öz

Abstract

Amaç
Kardiyopulmoner resüsitasyon (KPR) ve kardiyak arrest sonrası bakımdaki gelişmelere rağmen, hastane içi ve hastane dışı kardiyak arrest hastalarının sağ kalımı sırasıyla %15 ve %22 oranlarıyla hala düşüktür. Hedefe yönelik sıcaklık yönetiminin (TTM), hastane içinde veya dışında kardiyak arrest yaşayan hastaların nörolojik sonuçlarını iyileştirdiği gösterilmiştir. Bu retrospektif çalışmada, European Society of Intensive Care Medicine (ESICM) tarafından 2019 yılında en iyi TTM protokolü seçilen TTM protokolümüzün etkinliğini analiz etmeyi ve konvansiyonel ile mekanik TTM tekniklerini karşılaştırmayı amaçladık.

Yöntem
Bu retrospektif çalışmaya, başarılı bir resüsitasyondan sonraki ilk 6 saat içinde yoğun bakım ünitesine (YBÜ) kabul edilen erişkin hastalar dahil edilmiştir. Ocak 2013’ten Aralık 2017’ye kadar olan veriler hasta kayıtlarından toplandı. 18 yaşından küçük ve hipotermi süresi sonuna kadar hayatta kalamayan hastalar çalışma dışı bırakılmışlardır. Sıcaklık yönetiminin etkinliği için geleneksel TTM grubu (KH) ve TMS makine grubu karşılaştırıldı.

Bulgular
Dört yıllık bir süre boyunca, 1343 KPR sonrası hasta yoğun bakımda takip edildi. Bu 1343 hastanın %20,5’ine TTM tedavisi uygulandı. TTM hastalarının %62,04’ü (170) taburcu olup; %37,9’u (104) hayatını kaybederken; TTM tedavisi almayan hastaların sadece %27,44’ü (293) taburcu olabilmiştir. TTM hastalarının toplam sağ kalım oranları (KH ve TMS makine grubu) TTM uygulanmayan hastalara göre sırasıyla %62,04 ve %27,44 daha yüksekti (p<0,05). TMS makine grubu, KH grubundan (%66,4) daha iyi sağ kalım oranlarına sahipti. Ayrıca vücut sıcaklık değerlerinde dalgalanmalar TMS grubunda KH grubuna göre daha az gözlendi.

Sonuç
Kullanılan yöntemden bağımsız olarak başarılı bir KPR sonrası uygulanan TTM, sonuç üzerinde olumlu bir etkiye sahiptir. Önemli olan minimum dalgalanmalarla hedef sıcaklığı korumaktır. Standart bir protokol olmamasına rağmen, protokole dayalı bir TTM, kardiyak arrest sonrası hastalar için yararlı olabilir. Gelecekteki çalışmalar, TTM için en uygun protokolün geliştirilmesine yardımcı olabilir.

Keywords

Kardiyak arrest, sıcaklık, yoğun bakım

IMPROVED OUTCOMES WITH TARGETED TEMPERATURE MANAGEMENT (TTM): CLINICAL SIGNIFICANCE FOR POST-CARDIAC ARREST PATIENTS

Abstract

Objective
Despite advances in cardiopulmonary resuscitation (CPR) and post-cardiac arrest care, the survival of patients with in-hospital and out-of-hospital cardiac arrests are still low with the rates of 15% and 22%, respectively. Targeted temperature management (TTM) has been shown to improve neurologic outcome of patients who had either in or out-of-hospital cardiac arrests. In this retrospective study we aimed to analyze the effectiveness of our TTM protocol – chosen as the best TTM protocol by European Society of Intensive Medicine (ESICM) in 2019 and to compare conventional and mechanical TTM techniques.

Method
This retrospective study included adult post-CPR patients who were admitted to the intensive care unit (ICU) in the first 6 hours after a successful resuscitation. Data from January 2013 to December 2017 were collected from patients’ records. Patients younger than 18 years old and who could not survive till the end of hypothermia period were excluded. Conventional TTM group and TMS machine group were compared for the effectivity of temperature management.

Results
Over a 4-year period, 1343 post-CPR patients were followed up in ICU. Among these 1343 patients 20.5% were applied TTM treatment. While 62.04% (170) of TTM patients were discharged and 37.9% (104) have died; only 27.44% (293) of the patients who did not receive TTM treatment were discharged. Total survival rates of TTM patients (CH and TMS machine groups) were higher than the patients who were not applied TTM with the rate of 62.04% and 27.44% respectively (p<0.05). TMS machine group had better survival rates than CH group (66.4%). Also fluctuations of body temperature values were observed less in TMS group than CH Group.

Conclusion
TTM with no importance about the method being used, has a positive impact on outcome after a successful CPR. The important thing is maintaining the target temperature with minimal fluctuations. Although there is not a standard protocol, a protocol driven TTM may be useful for post cardiac arrest patients. Future studies may help improving an optimal protocol for TTM.

Keywords

Cardiac Arrest, temperature, intensive care unit

References

• Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016; 133:e38., Silverman MG, Scirica BM. Cardiac arrest and therapeutic hypothermia. Trends Cardiovasc Med. 2016 May;26(4):337-44. doi:10.1016/j.tcm.2015.10.002.
• Silverman MG, Scirica BM. Cardiac arrest and therapeutic hypothermia. Trends Cardiovasc Med. 2016 May;26(4):337- 44. doi: 10.1016/j.tcm.2015.10.002
• Chan PS, McNally B, Tang F, et al. Recent trends in survival from out-of-hospital cardiac arrest in the United States. Circulation. 2014; 130:1876–82,
• Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012; 367:1912–20.
• Booth CM, Boone RH, Tomlinson G, Detsky AS. Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. J Am Med Assoc 2004;291:870–9.
• Mitrani RD, Myerburg RJ. Editorial Commentary: The cold facts: Role of therapeutic hypothermia in cardiac arrest survivors. Trends Cardiovasc Med. 2016 May;26(4):345-7.
• Norman S. Abramson, M.D., Peter Safar, M.D., Katherine M. Detre, M.D., Dr. P.H., Sheryl F. Kelsey, Ph.D., at all. Randomized clinical study of thiopental loading in comatose survivors of cardiac arrest. Brain resuscitation clinical trial I study group. N Engl J Med 1986;314(7):397–403.
• Norman S. Abramson, M.D., Kim Sutton Tyrrell, Dr.P.H., Peter Safar, M.D., Katherine M. Detre, M.D., Dr.P.H., Sheryl F. Kelsey, at all. A randomized clinical study of a calciumentry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. Brain resuscitation clinical trial II study group. N Engl J Med 1991;324(18):1225–31.
• Roine RO, Kaste M, Kinnunen A, Nikki P, Sarna S, Kajaste S. Nimodipine after resuscitation from out-of-hospital ventricular fibrillation A placebo-controlled, double-blind, randomized trial. JAMA 1990;264(24):31717.
• Chan PS, Berg RA, Tang Y, Curtis LH, Spertus JA; American Heart Association’s Get With the Guidelines–Resuscitation Investigators. Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest. JAMA. 2016 Oct 4;316(13):1375-1382.
• 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Medicine Part, 7.5: Postresuscitation Support. Circulation 2005; 112: IV-84–IV-88.
• Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: postcardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122: S768–786.
• Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2015 Oct;95:202-22. doi: 10.1016/j.resuscitation.2015.07.018.
• Nolan JP, Sandrio C, Böttiger B,et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care, Resuscitation 2021, https://doi.org/10.1016/j.resuscitation.2021.02.012
• Post-resuscitation care Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2): S465-82. doi: 10.1161/CIR.0000000000000262.
• Arrich J, Holzer M, Havel C, et al. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2016; 2:CD004128.
• Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013; 369:2197-2206.
• Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346(8):557–563. [PubMed: 11856794].
• Hachimi-Idrissi S, Zizi M, Nguyen DN, et al. The evolution of serum astroglial S-100 beta protein in patients with cardiac arrest treated with mild hypothermia. Resuscitation. 2005; 64(2):187–192. [PubMed: 15680528].
• Kamarainen A, Virkkunen I, Tenhunen J, Yli-Hankala A, Silfvast T. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand. 2009; 53(7):900–907. [PubMed: 19496762]
• The Hypothermia After Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac Arrest. N Engl J Med. 2002; 346(8):549–556. [PubMed:11856793]
• Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med. 2012; 40(3):747–753. [PubMed: 22020244]
• Eleonora Tommasi, Chiara Lazzeri, Pasquale Bernardo, Andrea Sori, Marco Chiostri, Gian F. Gensini and Serafina Valente. Cooling techniques in mild hypothermia after cardiac arrest. J Cardiovasc Med 2017, 18:459–466.
• Kim F, Olsufka M, Longstreth WT, et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation 2007; 115:3064– 3070.
• Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med 2012; 40:747–753.
• N Deye, A Cariou, P Girardie, N Pichon, B Megarbane, P Midez et al. Endovascular Versus External Targeted Temperature Management for Patients With Out-of- Hospital Cardiac Arrest A Randomized, Controlled Study. Circulation. 2015;132:182-193. DOI: 10.1161/ CIRCULATIONAHA.114.012805
• Tømte Ø, Drægni T, Mangschau A, Jacobsen D, Auestad B, Sunde K. A comparison of intravascular and surface cooling techniques in comatose cardiac arrest survivors. Crit Care Med 2011; 39: 443-449.
• Jun GS, Kim JG, Choi HY, et al. A comparison of intravascular and surface cooling devices for targeted temperature management after out-of-hospital cardiac arrest: A nationwide observational study. Medicine (Baltimore). 2019;98(30): e16549. doi:10.1097/MD.0000000000016549.
• Ki Hong Kim, Sang Do Shin, Kyoung Jun Song, Young Sun Ro, Yu Jin Kim, Ki Jeong Hong, Joo Jeong, Jeong Ho Park, Tae Han Kima, So Yeon Kong. Cooling methods of targeted temperature management and neurological recovery after out-of-hospital cardiac arrest: A nationwide multicenter multi-level analysis. Resuscitation 125 (2018) 56–65.
• Haugk M, Sterz F, Grassberger M, et al. Feasibility and efficacy of a new noninvasive surface cooling device in postresuscitation intensive care medicine. Resuscitation 2007; 75:76–81.