Grade B Recommendation
Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
This review may be
edited
Author info
Posted By:
Anthony Delaney and Gordon Doig
E-Mail:
apdelane@doh.health.nsw.gov.au Gordon.Doig@EvidenceBased.net
Posted Date:
September 9th, 2002
Title:
Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
PubMed Resource Link:
Click here to repeat the Medline search used to develop this EBR.
Evidence-based Recommendation
Best level of evidence
A well conducted
Level II
randomized controlled trial.
Target Population
Patients with witnessed arrest/collapse of presumed cardiac origin with either VF or VT on initial ECG
Estimated time of between 5 to 15 minutes from the patient's collapse to the first attempt at resuscitation by emergency medical personnel.
An interval of no more than 60 minutes from time of collapse to restoration of spontaneous circulation.
Patient should be unable to obey commands on arrival at hospital.
Purpose
To improve the number of patients with a 'favorable' neurologic outcome from 39% to 55% (p=0.013) and to improve the number of survivors from 41% to 55% (p=0.018)
Exclusion criteria
Mean arterial pressure less than 60mmHg for more than 30 minutes
Evidence of hypoxia. (Ex. desaturations to less than 85% for more than 15 minutes).
Known terminal illness.
Prexisting coagulopathy.
Recommendation
Commence surface cooling and ice packs (to groin, neck and axillae) as soon as possible.
Target temperature of 32 - 34ºC, continued for 24 hours from the start ofcooling.
Patients should be monitored with a continuous core temperature monitor (eg. bladder, PA catheter) as soon as possible.
All patients will be intubated and mechanically ventilated.
Sedation with midazolam and opiods as required to facilitate mechanical ventilation.
Neuromuscular blockade during the period of cooling prevents shivering.
After 24 hours allow passive rewarming.
Potential harm
There are trends towards increased rate of sepsis (13% v's 7%) and pneumonia (37% v's 29%) in patients treated with hypothermia.
Bleeding is also a potential problem with a trend towards increased bleeding in the hypothermia group (35% v's 26%). This may be more problematic if thrombolytic therapy is used or anticoagulants, anti-platelet agents are used in conjunction with acute angiography/angioplasty.
Hypothermia may induce haemodynamic instability and dysrhthymia that could require cessation of cooling.
Development Information
Date EBR last updated
September 10th, 2002
Literature source and search terms
Medline was searched using PubMed with the following terms:
cardiopulmonary resuscitation AND
hypothermia AND
(random* OR "systematic review*" OR meta-analysis OR guidelines OR randomized controlled trials OR randomized controlled trial OR systematic [sb])
Study selection
32 abstracts were retrieved and hand searched.
There was one
Level II
RCT and one pseudo randomized trial considering clinically meaningful outcomes.
The Level II RCT was appraised and interpreted in consideration of the results of the pseudo randomized trial.
References
Mild therpeutic hyopthermia to improve neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-556 (Level II)
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;246:557-63. (Level III - pseudo-randomised)
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Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
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