Gail Delfin

Haemodynamic management strategies are not explicitly defined in the majority of therapeutic hypothermia implementation studies

BACKGROUND Therapeutic hypothermia (TH) has revolutionized the management of comatose post-cardiac arrest syndrome (PCAS) patients. The 2008 ILCOR/AHA Consensus Statement for the treatment of PCAS suggests that goal-directed therapy, targeting mean arterial pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation (ScvO(2)), should be employed to normalize oxygen delivery. However, the optimal PCAS haemodynamic management strategy has not been defined and few objective data exist to guide clinicians. OBJECTIVE To describe the haemodynamic strategies used in TH implementation studies. METHODS A Medline search (time period, 3/2002 to 3/2010) was performed using the terms cardiac arrest and hypothermia, induced, then limited post-search to implementation studies of TH in comatose adults. The identified studies were examined for explicit definitions of the following terms: MAP; systolic blood pressure (SBP), CVP, ScvO(2), pulmonary artery catheter (PAC), echocardiogram (ECHO), lactate, and volume status. RESULTS Forty-four implementation studies were identified and 43% (19/44) of them mentioned haemodynamics in any fashion. At least one haemodynamic goal was specifically defined in 16/44 (36%). The median number defined was 4 (range 1-6); individual goals as follows: MAP, 13/44 (30%); SBP, 3/44 (7%); CVP, 5/44 (11%); ScvO(2), 4/44 (9%); PAC, 7/44 (16%); ECHO, 7/44 (16%); lactate, 5/44 (11%); and volume status, 8/44 (18%). CONCLUSIONS Specific haemodynamic goals are defined in a minority of published TH implementation studies. Given the volatile haemodynamics of the PCAS and lack of consensus on an optimal resuscitation strategy, explicit description of haemodynamic goals should be provided in future studies.

Telemedicine REsuscitation and Arrest Trial (TREAT): A feasibility study of real-time provider-to-provider telemedicine for the care of critically ill patients

Background Protocol-based resuscitation strategies in the Emergency Department (ED) improve survival for out-of-hospital cardiac arrest (OHCA) and severe sepsis but implementation has been inconsistent. Objective To determine the feasibility of a real-time provider-to-provider telemedical intervention for the treatment of OHCA and severe sepsis. Materials and methods A three-center pilot study utilizing a “hub-spoke model” with an academic medical center acting both as the hub for teleconsultation as well as a spoke hospital enrolling patients. Eligible patients were adults presenting with either return of spontaneous circulation (ROSC) following OHCA or with severe sepsis. Telemedical encounters were monitored for quality of interface and patient level data (demographics, physiologic, laboratory, treatment) were abstracted. Results Over a 12-week period, there were 80 text alerts. Of 38 OHCA alerts, 13 achieved ROSC (34.2%), 85% underwent teleconsultation (11/13). Of 42 “lactate ≥4 mmol/L” alerts, 33.3% (14/42) were determined to have severe sepsis and underwent teleconsultation. Mean time from OHCA teleconsultation request to live connection: 3.7 min (95% CI 1.6–5.8); mean call duration: 71.7 min (95% CI 34.6–108.8). Mean time from sepsis teleconsultation request to connection: 8.4 min (95% CI 4.5–12.3); mean call duration: 61.5 min (95% CI 37.2–85.8). Discussion Telemedicine provides a robust and reliable means of quickly bringing expertise virtually to the bedside at the most proximal point in a patient’s hospital care. Conclusions Real time ED-based telemedical consultation for patients with ROSC after OHCA or severe sepsis has the potential to improve the dissemination and implementation of evidence-based care.

Variability in Postarrest Targeted Temperature Management Practice: Implications of the 2015 Guidelines

In 2002 postarrest care was significantly altered when multiple randomized controlled trials found that therapeutic hypothermia at a goal temperature of 32-34°C significantly improved survival and neurologic outcomes. In 2013, targeted temperature management (TTM) was reexamined via a randomized controlled trial between 33°C and 36°C in post-cardiac arrest patients and found similar outcomes in both cohorts. Before the release of the 2015 American Heart Association (AHA) Guidelines, our group found that across hospitals in the United States, and even within the same institution, TTM protocol variability existed. After the 2013 TTM trial, it was anticipated that the 2015 Guidelines would clarify which target temperature should be used during postarrest care. The AHA released their updates for post-cardiac arrest TTM recently and, based on the literature available, have recommended the use of TTM at a goal temperature between 32°C and 36°C. Whether this variability has an effect on TTM implementation or patient outcomes is unknown.

A structured educational intervention to improve targeted temperature management utilization after cardiac arrest

PURPOSE Post-arrest targeted temperature management (TTM) has been shown to dramatically improve outcomes after resuscitation, yet studies have revealed inconsistent and slow adoption. Little is known about barriers to TTM implementation and methods to increase adoption. We hypothesized that a structured educational intervention might increase TTM use. MATERIALS AND METHODS Subjects participated in mixed quantitative/qualitative surveys before and after attending a series of TTM educational courses from October 2010 to October 2011, to determine usage and barriers to implementation. A knowledge examination was also administered to participants before and after the course. RESULTS Clinicians completed 227 surveys (129 pre-training and 98 post-training) and 343 exams (165 pre-training and 178 post-training). A ranking survey (score range 1-7; 7 as most challenging) found that communication challenges (mean score 4.7 ± 1.5) and lacking adequate education (4.3 ± 1.9) were the 2 most emphasized barriers to implementation. Post-survey results found that 95% (93/98) of respondents felt more confident initiating TTM post-intervention. There was a statistically significant increase in self-reported TTM usage after participation in the program (P < .01). CONCLUSIONS A focused TTM program led to increased confidence and usage among participants. Future work will focus on targeted training to address specific barriers and increase TTM utilization.

Factors associated with re-arrest following initial resuscitation from cardiac arrest

BACKGROUND To examine patient- and arrest-level factors associated with the incidence of re-arrest in the hospital setting, and to measure the association between re-arrest and survival to discharge. METHODS This work represents a retrospective cohort study of adult patients who were successfully resuscitated from an initial out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (ICHA) of non-traumatic origin at two urban academic medical centers. In this study, re-arrest was defined as loss of a pulse following 20min of sustained return of spontaneous circulation (ROSC). RESULTS Between 01/2005 and 04/2016, 1961 patients achieved ROSC following non-traumatic cardiac arrest. Of those, 471 (24%) experienced at least one re-arrest. In re-arrest patients, the median time from initial ROSC to first re-arrest was 5.4h (IQR: 1.1, 61.8). The distribution of initial rhythms between single- and re-arrest patients did not vary, nor did the median duration of initial arrest. Among 108 re-arrest patients with an initial shockable rhythm, 60 (56%) experienced a shockable re-arrest rhythm. Among 273 with an initial nonshockable rhythm, 31 (11%) experienced a shockable re-arrest rhythm. After adjusting for significant covariates, the incidence of re-arrest was associated with a lower likelihood of survival to discharge (OR: 0.32; 95% CI: 0.24-0.43; p<0.001). CONCLUSIONS Re-arrest is a common complication experienced by cardiac arrest patients that achieve ROSC, and occurs early in the course of their post-arrest care. Moreover, re-arrest is associated with a decreased likelihood of survival to discharge, even after adjustments for relevant covariates.

Postarrest targeted temperature management immediately following craniotomy-a case report.

Therapeutic hypothermia or targeted temperature management (TTM) has been shown to improve survival and neurological outcome after cardiac arrest. TTM is not frequently utilized in the postoperative setting because of the concern for exacerbation of bleeding. We present the case of a 65-year-old man who had a cardiac arrest during craniotomy for a brain tumor resection. He was successfully resuscitated from pulseless electrical activity and remained unresponsive. After assessment for postoperative brain hemorrhage, the neurocritical care team initiated TTM. Repeat imaging revealed no additional bleeding. The patient was discharged with a cerebral performance category of 1 to an acute rehabilitation center 11 days following his cardiac arrest. This case highlights the need for further consideration of TTM in the postoperative cardiac arrest population.