Intra-arrest therapeutische hypothermie

Fabienne Roossien, AIOS SEHRegionaal refereren 18-07-2013

Inhoud• Achtergrond• Search• Studies• Conclusie • Discussie• THM

Achtergrond• Dierstudies:– Intra-arrest TH 1-4 : • betere kans op ROSC & survival• betere neurologische uitkomst

• Veilig, uitvoerbaar 5-7

• Effect mensen?

Search

Search• Medline/CINAHL:– Intra-arr*/ intra arr* AND hypothermia– 27 hits => 2 relevant

• Embase– Therapeutic/Induced hypothermia AND intra-

arrest– 63 hits=> 6 relevant, 3 cf. pubmed, 3 abstracts

(2 AHA congres 2011; 1 Critical Care congres 2011)

Artikelen• Castren et al.

Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC intranasal cooling effectiveness). Circulation 2010; 122: 729-736

• Garret et al.The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrestResuscitation 82 (2011) 21–25

Abstracts• J. Freese

Intra-arrest induction of therapeutic hypothermia via large-volume ice-cold saline infusion improves immediate outcomes for out-of-hospital cardiac arrest

Intra-arrest induction of therapeutic hypothermia via large-volume, ice-cold saline infusion results in improved outcomes among out-of-hospital cardiac arrests of cardiac etiologyCirculation 2011 124: A97& A2

• Castren et al.Earlier intra-arrest transnasal cooling may be beneficialCritical care 2011, 15(suppl):P303

Auteur

Patient groep

Studie type

Inter-ventie

Vergelijking

Outcomes Resultaten Study Weaknessess

Level

Castren et al.2010

194ptn>18jr met OHCA

93 IATH101 control

Prospectief RCT

IATH d.m.v. trans-nasal cooling(rhino chill)

Geen IATH Efficacy:coolingrates

ROSC rates

Survival to discharge

Neurologische outcome bij ontslag

Vergelijkbare groepen

ROSC:IATH 37,6% vs 42,6% (p 0,48)

Survival:IATH 43,8% vs 31% (p 0,26)

Neuro:IATH 34,4% vs 21,4% (p 0,21)

CPR<10min:ROSC IATH 56,5% vs 29,4% (p 0,04)

Neuro: IATH 43,5% vs 17,6% (p 0,03)

Verschil tijd tot intubatie (niet verklaard)

Manier van koelen

2

Auteur

Patient groep

Studie type

Inter-ventie

Vergelijking

Outcomes Resultaten Study Weaknessess

Level

Garret et al.

2011

542 ptn>18jrmet OHCA

208 IATH334 niet

Retrospectief

History-control

Intra-arrest TH: 2L 4gr NaCl 0,9%Max. 2LIntra-arrest

Geen intra-arrest TH

Time to ROSC

Survival admission

Survival discharge

Vergelijkbare groepen

36,5% ROSC IATH-groep vs. 26,9%(p 0,018)

OR 1,83

Niet significant:28,4% survival bij opname vs 23,4%

12,5% survival tot ontslag vs 12%

>700cc koud zout significant vaker ROSC pre-hospital

Retrospectief

Vulling met koude infusie versus geen vulling

Verschillend moment in tijd

4

Auteur

Patient groep

Studie type

Inter-ventie

Vergelij-king

Outcomes Resultaten Study Weaknessess

Level

Freese et al.

2011

8040OHCA(cardiale oorzaak)

4459 control3581 TH

Retro-spectief

Historycontrol

Intra-arrest TH met koud NaCl 0,9%

Geen intra-arrest TH

Directe overleving

Vergelijkbare groepen

6,5% vs. 7,8% witnessed arrests (p0,03)

31,1% vs. 26,8% ROSC(p<0,0001)

23,6% vs. 19,9%blijvend ROSC(p<0,0001)

Abstract

Retrospectief

Groepen verschillend moment behandeld

ntb

Freese et al.

10309 OHCA (niet trauma)

5582 control4727 TH

“ “ “ “ 8,3% vs. 9,5% witnessed arrest(p0,026)

31,7% vs. 29%ROSC(p<0,003)

24,1% vs. 21,9%blijvend ROSC(p<0,0014)

“ ntb

Auteur

Patient groep

Studie type

Inter-ventie

Vergelijking

Outcomes Resultaten Study Weaknessess

Level

Castren

2011

41 ptn met OHCA

19 IATH22 control

ProspectiefRCT

IATH d.m.v. trans-nasal cooling(Rhino chill)

Geen IATH ROSC rate ROSCIATH 42% vs 36% control

Site 1: cooling @ 11 min

ROSC50% IATH vs 11% control (CPR IATH 5min vs 7min control)

Site 2: cooling@20min

ROSC39% IATH vs 54% control(CPR IATH 7min vs 9min control)

Abstract

Verschil in start CPR en cooling

ntb

Conclusie studies

• IATH middels infusie/transnasaal• Veilig en haalbaar• Trend naar meer ROSC, • Wschl. ook meer survival en betere neurologie • M.n. bij snelle start CPR en snelle start IATH

Discussie• Beperkte humane studies• Abstracts veelbelovend, grote

aantallen, nog niet uitgewerkt• Meer ROSC bij IATH • Relatie ROSC-survival-neurologie nog

niet bewezen

• Meer RCT’s nodig met primaire doel survival/ neurologie

THM• O.b.v. eerder onderzoek: – geen adverse events, IATH haalbaar,

neiging naar meer ROSC

• Positief effect• Echter: veilig en haalbaar, dus…

• Keep it cool & fast!

Vragen?

Referenties1. Nozari et al. Critical time window for intra-arrest cooling with cold-saline flush in a dog model of CPR

Circulation 2006; 113; 2690-62. Zhao et al. Intra-arrest cooling with delayed reperfusion yields higher survival than earier normothermic

resuscitatoion in a mouse-model. Resuscitation 2008; 77:242-93. Abella et al. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation 2004;

109:2786-914. Menegazzi et al Effects of pre-arrest and intra-arrest hypothermia on ventricular defirillation and resuscitation

Resuscitation 2009; 80:126-325. Bernard et al. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of

out-of-hospital cardiac arrest: a preliminary report. Resuscitation 2003, 56:9-13.6. Kim F et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-ofhospital cardiac

arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation 2007, 115:3064-3070.7. Virkkunen I et al. Induction of therapeutic hypothermia after cardiac arrest in prehospital patients using ice-

cold Ringer's solution: a pilot study. Resuscitation 2004, 62:299-302.8. Castren et al. Intra-arrest transnasalevaporative cooling: a randomized, prehospital, multicenter study

(PRINCE: Pre-ROSC intranasal cooling effectiveness). Circulation 2010; 122: 729-7369. Garret et al. The association between intra-arrest therapeutic hypothermia and return of spontaneous

circulation among individuals experiencing out of hospital cardiac arrest Resuscitation 82 (2011) 21–2510. Scolletta et al. Intra-arrest hypothermia during cardiac arrest: a systematic review. Critical Care 2012, 16:R4111. Freese Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume, Ice-Cold Saline Infusion Results in

Improved Outcomes Among Out-of-Hospital Cardiac Arrests of Cardiac Etiology 12. Freese Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume Ice-Cold Saline Infusion Improves

Immediate Outcomes for Out-of-Hospital Cardiac Arrest13. Castren et al . Earlier intra-arrest transnasal cooling may be beneficial

Critical care 2011, 15(suppl):P303