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Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline.

ABSTRACT: Pre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service. The safety and impact on the clinical outcome have also been analyzed.We performed a prospective observational study with a retrospective control group. A total of 40 patients were cooled by an intravenous administration of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital (TH group). The pre-hospital decrease of tympanic temperature (TT) was analyzed as the primary endpoint. Patients in the control group did not undergo any pre-hospital cooling.In the TH group, administration of 12.6 ± 6.4 ml/kg of 4°C cold normal saline was followed by a pre-hospital decrease of TT of 1.4 ± 0.8°C in 42.8 ± 19.6 min (p < 0.001). The most effective cooling was associated with a transport time duration of 38-60 min and with an infusion of 17 ml/kg of cold saline. In the TH group, a trend toward a reduced need for catecholamines during transport was detected (35.0 vs. 52.5%, p = 0.115). There were no differences in demographic variables, comorbidities, parameters of the cardiopulmonary resuscitation and in other post-resuscitation characteristics. The coupling of pre-hospital cooling with subsequent in-hospital TH predicted a favorable neurological outcome at hospital discharge (OR 4.1, CI95% 1.1-18.2, p = 0.046).Pre-hospital induction of TH by the rapid intravenous administration of cold normal saline has been shown to be efficient even with a lower dose of coolant than reported in previous studies. This dose can be associated with a favorable impact on circulatory stability early after the return of spontaneous circulation and, when coupled with in-hospital continuation of cooling, can potentially improve the prognosis of patients.ClinicalTrials (NCT): NCT00915421.

SUBMITTER: Skulec R

PROVIDER: S-EPMC3219975 | biostudies-literature | 2010

REPOSITORIES: biostudies-literature

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Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline.

Skulec Roman R Truhlár Anatolij A Seblová Jana J Dostál Pavel P Cerný Vladimír V

Critical care (London, England) 20101222 6

<h4>Introduction</h4>Pre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service ...[more]

PMID: 21176218

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Project description:BackgroundMild therapeutic hypothermia (TH), or targeted temperature management, improves survival and neurological outcomes in patients after out-of-hospital cardiac arrest (OHCA). International guidelines strongly support initiating TH for all eligible individuals presenting with OHCA; however, the timing of cooling initiation remains uncertain. This systematic review and meta-analysis was conducted with all available randomised controlled trials (RCTs) included to explore the efficacy and safety of initiating pre-hospital TH in patients with OHCA.MethodsThe MEDLINE and Cochrane databases were searched from inception to October 2017. Inclusion criteria for full-text review included RCTs comparing pre-hospital TH with no pre-hospital TH after cardiac arrest, patients > 14 years of age with documented cardiac arrest from any rhythm, and outcome data that included survival to hospital discharge and temperature at hospital arrival. Results of retrieved studies were compared through meta-analysis using random effects modelling.ResultsA total of 10 trials comprising 4220 patients were included. There were no significant differences between the two arms for the primary outcome of neurological recovery (risk ratio [RR] 1.04, 95% CI 0.93-1.15) or the secondary outcome of survival to hospital discharge (RR 1.01, 95% CI 0.92-1.11). However, there was a significantly lower temperature at hospital arrival in patients receiving pre-hospital TH (mean difference - 0.83, 95% CI - 1.03 to - 0.63). Pre-hospital TH significantly increased the risk of re-arrest (RR 1.19, 95% CI 1.00 to 1.41). No survival differences were observed among subgroups of patients who received intra-arrest TH vs post-arrest TH or who had shockable vs non-shockable rhythms.ConclusionsPre-hospital TH after OHCA effectively decreases body temperature at the time of hospital arrival. However, it does not improve rates of survival with good neurological outcome or overall survival and is associated with increased rates of re-arrest.

Project description:AimThe COVID-19 pandemic has significantly impacted Emergency Medical Services (EMS) operations throughout the country. Some studies described variation in total volume of out-of-hospital cardiac arrests (OHCA) during the pandemic. We aimed to describe the changes in volume and characteristics of OHCA patients and resuscitations in one urban EMS system.MethodsWe performed a retrospective cohort analysis of all recorded atraumatic OHCA in Marion County, Indiana, from January 1, 2019 to June 30, 2019 and from January 1, 2020 to June 30, 2020. We described patient, arrest, EMS response, and survival characteristics. We performed paired and unpaired t-tests to evaluate the changes in those characteristics during COVID-19 as compared to the prior year. Data were matched by month to control for seasonal variation.ResultsThe total number of arrests increased from 884 in 2019 to 1034 in 2020 (p = 0.016). Comparing 2019 to 2020, there was little difference in age [median 62 (IQR 59-73) and 60 (IQR 47-72), p = 0.086], gender (38.5% and 39.8% female, p = 0.7466, witness to arrest (44.3% and 39.6%, p = 0.092), bystander AED use (10.1% and 11.4% p = 0.379), bystander CPR (48.7% and 51.4%, p = 0.242). Patients with a shockable initial rhythm (19.2% and 15.4%, p = 0.044) both decreased in 2020, and response time increased by 18 s [6.0 min (IQR 4.5-7.7) and 6.3 min (IQR 4.7-8.0), p = 0.008]. 47.7% and 54.8% (p = 0.001) of OHCA patients died in the field, 19.7% and 19.3% (p = 0.809) died in the Emergency Department, 21.8% and 18.5% (p = 0.044) died in the hospital, 10.8% and 7.4% (p = 0.012) were discharged from the hospital, and 9.3% and 5.9% (p = 0.005) were discharged with Cerebral Performance Category score ≤ 2.ConclusionTotal OHCA increased during the COVID-19 pandemic when compared with the prior year. Although patient characteristics were similar, initial shockable rhythm, and proportion of patients who died in the hospital decreased during the pandemic. Further investigation will explore etiologies of those findings.

Project description:ImportanceOut-of-hospital cardiac arrest (OHCA) health care provision may be a good indicator of the recovery of the health care system involved in OHCA care following the COVID-19 pandemic. There is a lack of data regarding outcomes capable of verifying this recovery.ObjectiveTo determine whether return to spontaneous circulation, overall survival, and survival with good neurological outcome increased in patients with OHCA since the COVID-19 pandemic was brought under control in 2022 compared with prepandemic and pandemic levels.Design, setting, and participantsThis observational cohort study was conducted to examine health care response and survival with good neurological outcome at hospital discharge in patients treated following OHCA. A 3-month period, including the first wave of the pandemic (February 1 to April 30, 2020), was compared with 2 periods before (April 1, 2017, to March 31, 2018) and after (January 1 to December 31, 2022) the pandemic. Data analysis was performed in July 2023. Emergency medical services (EMS) serving a population of more than 28 million inhabitants across 10 Spanish regions participated. Patients with OHCA were included if participating EMS initiated resuscitation or continued resuscitation initiated by a first responder.ExposureThe pandemic was considered to be under control following the official declaration that infection with SARS-CoV-2 was to be considered another acute respiratory infection.Main outcome and measuresThe main outcomes were return of spontaneous circulation, overall survival, and survival at hospital discharge with good neurological outcome, expressed as unimpaired or minimally impaired cerebral performance.ResultsA total of 14 732 patients (mean [SD] age, 64.2 [17.2] years; 10 451 [71.2%] male) were included, with 6372 OHCAs occurring during the prepandemic period, 1409 OHCAs during the pandemic period, and 6951 OHCAs during the postpandemic period. There was a higher incidence of OHCAs with a resuscitation attempt in the postpandemic period compared with the pandemic period (rate ratio, 4.93; 95% CI, 4.66-5.22; P < .001), with lower incidence of futile resuscitation for OHCAs (2.1 per 100 000 person-years vs 1.3 per 100 000 person-years; rate ratio, 0.81; 95% CI, 0.71-0.92; P < .001). Recovery of spontaneous circulation at hospital admission increased from 20.5% in the pandemic period to 30.5% in the postpandemic period (relative risk [RR], 1.08; 95% CI, 1.06-1.10; P < .001). In the same way, overall survival at discharge increased from 7.6% to 11.2% (RR, 1.45; 95% CI, 1.21-1.75; P < .001), with 6.6% of patients being discharged with good neurological status (Cerebral Performance Category Scale categories 1-2) in the pandemic period compared with 9.6% of patients in the postpandemic period (RR, 1.07; 95% CI, 1.04-1.10; P < .001).Conclusions and relevanceIn this cohort study, survival with good neurological outcome at hospital discharge following OHCA increased significantly after the COVID-19 pandemic.

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Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline.

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Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline.

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