Top Things to Know: Science Advisory on Temperature Management for Comatose Adult Survivors of Cardiac Arrest
Prepared by Amber Rodriguez, PhD, ECC/HBS Science and Health Advisor
- Neurologic injury remains the most common cause of death in patients who achieve return of spontaneous circulation after cardiac arrest.
- Temperature management, historically at mildly hypothermic temperatures, has been used widely since 2002 as the main treatment thought to improve neurologic outcome after cardiac arrest
- A large trial (Dankiewicz 2021) including patients with OHCA of presumed cardiac etiology, published in 202, raised questions about whether temperature management at sub-normal temperatures truly improves outcomes.
- Due to this and other recent trials, some organizations have begun to recommend a normothermic temperature target for most patients.
- The present paper examines the recent OHCA trial and discusses how to interpret the results when choosing a post-arrest temperature management strategy in the North American post-cardiac arrest population.
- While recent trials support normothermia being an evidence-based approach for many patients, many post-cardiac arrest patients in North America do not meet inclusion criteria for the “TTM” trials, including Dankiewicz et al, and it remains unclear whether patients with different etiology of arrest and perhaps higher risk for brain injury might benefit from different target temperatures.
- When using a normothermia strategy, active temperature control is often still needed (devices were required to prevent fever in 46% of patients in the normothermia arm in the trial).
- Much of the benefit seen previously from mild hypothermia might be due to the “bundle of care,” including avoiding inappropriately early neuroprognostication. Use of normothermia instead of hypothermia should not lead to earlier neuroprognostication.
- The Dankiewicz trial (“TTM2”) supports a normothermic temperature strategy for patients similar to those included in the trial (OHCA of presumed cardiac cause, all rhythms except unwitnessed asystole). It remains unclear whether some subgroups of post-arrest patients with coma who do not meet those trial criteria might benefit from other target temperatures.
- This statement does not change the current AHA guidelines, but supports the validity of a normothermic approach for many comatose post-cardiac arrest patients. Changes in temperature management strategy should not lead to changes in other aspects of postarrest care, including avoiding inappropriately early neuroprognostication.
Citation
Perman SM, Bartos JA, Del Rios M, Donnino MW, Hirsch KG, Jentzer JC, Kudenchuk PJ, Kurz MC, Maciel CB, Menon V, Panchal AR, Rittenberger JC, Berg KM; on behalf of on behalf of the American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and Stroke Council. Temperature management for comatose adultsurvivors of cardiac arrest: a science advisory from the American Heart Association [published online ahead ofprint August 16, 2023]. Circulation. doi: 10.1161/CIR.0000000000001164