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Background and Objectives: The purpose of the study is to assess parental experiences of therapeutic hypothermia for moderate to severe hypoxic-ischemic encephalopathy with the goal of improving local clinical practice guidelines and fostering family-integrated care in neonates with hypoxic-ischemic encephalopathy. Methods: This single-center retrospective cross-sectional study included neonates and their parents registered in the Swiss National Asphyxia and Cooling Register between 2011 and 2021. Based on a literature review, an anonymous survey of parents of neonates with hypoxic-ischemic encephalopathy was developed and conducted using an online survey tool. Descriptive statistics were used to analyze the survey results. Results: The overall response rate to this survey was 64% (46/72). Sufficient information about hypoxic-ischemic encephalopathy was reported by 78% (36/46) of parents and sufficient information about the process of therapeutic hypothermia by 87% (40/46) of parents. The majority of parents indicated the need for, and at least a satisfactory perception of, professional (91%; 42/46) and emotional (87%; 40/46) support. Parents identified fostering family involvement and regular family communication that focuses on family integrated care as areas for improvement. Conclusions: There is still an unmet need for multidisciplinary teams to provide professional, empathetic, high quality, and family-integrated care to families with a neonate receiving therapeutic hypothermia for moderate or severe hypoxic-ischemic encephalopathy. [ABSTRACT FROM AUTHOR]

The article in Critical Care Medicine discusses the potential benefits of combining hydrogen inhalation and targeted temperature management for improving neurologic outcomes in patients resuscitated from out-of-hospital cardiac arrest. The study highlights the importance of individualized treatment timing and duration, as well as the need for more comprehensive neuropsychological assessments to evaluate patient outcomes accurately. Future research should focus on long-term neurologic recovery, safety in specific populations, and integrating this treatment into emergency care protocols to maximize its clinical value. [Extracted from the article]

Targeted temperature management has been a cornerstone of post-cardiac arrest care for patients remaining unresponsive after return of spontaneous circulation since the initial trials in 2002 found that mild therapeutic hypothermia improves neurological outcome. The suggested temperature range expanded in 2015 in response to a large trial finding that outcomes were not better with treatment at 33° C compared with 36° C. In 2021, another large trial was published in which outcomes with temperature control at 33° C were not better than those of patients treated with a strategy of strict normothermia. On the basis of these new data, the International Liaison Committee on Resuscitation and other organizations have altered their treatment recommendations for temperature management after cardiac arrest. The new American Heart Association guidelines on this topic will be introduced in a 2023 focused update. To provide guidance to clinicians while this focused update is forthcoming, the American Heart Association's Emergency Cardiovascular Care Committee convened a writing group to review the TTM2 trial (Hypothermia Versus Normothermia After Out-of-Hospital Cardiac Arrest) in the context of other recent evidence and to present an opinion on how this trial may influence clinical practice. This science advisory was informed by review of the TTM2 trial, consideration of other recent influential studies, and discussion between cardiac arrest experts in the fields of cardiology, critical care, emergency medicine, and neurology. Conclusions presented in this advisory statement do not replace current guidelines but are intended to provide an expert opinion on novel literature that will be incorporated into future guidelines and suggest the opportunity for reassessment of current clinical practice. [ABSTRACT FROM AUTHOR]

Objective: Temperature abnormalities are recognized as a marker of human disease, and the therapeutic value of temperature is an attractive treatment target. The objective of this synthetic review is to summarize and critically appraise evidence for active temperature management in critically ill patients.Data Sources: We searched MEDLINE for publications relevant to body temperature management (including targeted temperature management and antipyretic therapy) in cardiac arrest, acute ischemic and hemorrhagic stroke, traumatic brain injury, and sepsis. Bibliographies of included articles were also searched to identify additional relevant studies.Study Selection: English-language systematic reviews, meta-analyses, randomized trials, observational studies, and nonhuman data were reviewed, with a focus on the most recent randomized control trial evidence.Data Extraction: Data regarding study methodology, patient population, temperature management strategy, and clinical outcomes were qualitatively assessed.Data Synthesis: Temperature management is common in critically ill patients, and multiple large trials have been conducted to elucidate temperature targets, management strategies, and timing. The strongest data concerning the use of therapeutic hypothermia exist in comatose survivors of cardiac arrest, and recent trials suggest that appropriate postarrest temperature targets between 33°C and 37.5°C are reasonable. Targeted temperature management in other critical illnesses, including acute stroke, traumatic brain injury, and sepsis, has not shown benefit in large clinical trials. Likewise, trials of pharmacologic antipyretic therapy have not demonstrated improved outcomes, although national guidelines do recommend treatment of fever in patients with stroke and traumatic brain injury based on observational evidence associating fever with worse outcomes.Conclusions: Body temperature management in critically ill patients remains an appealing therapy for several illnesses, and additional studies are needed to clarify management strategies and therapeutic pathways. [ABSTRACT FROM AUTHOR]

Objectives: Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated.Design: Retrospective observational study.Setting: Patients reported in Extracorporeal Life Support Organization Registry.Patients: Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS.Interventions: Trends in bleeding complications, bleeding risk factors, and mortality.Measurement and Main Results: Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls.Conclusions: A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether the recommended observation period of 7 days for cardiac arrest survivors is sufficient for conscious recovery and to identify the variables associated with eventual neurologic recovery among patients with delayed awakening.Design: A retrospective cohort study.Setting: A single tertiary medical center.Patients: Five-hundred twenty-nine nontraumatic adult cardiac arrest survivors with prearrest favorable neurologic function (Cerebral Performance Category 1-2) who survived to hospital discharge during 2011-2019.Interventions: The enrolled patients were classified into favorable (Cerebral Performance Category 1-2) and poor (Cerebral Performance Category 3-4) neurologic recovery according to their neurologic function at hospital discharge. Among patients with favorable neurologic recovery, those who recovered within 7 days were assigned to the early recovery group or after 7 days as the late recovery group.Measurements and Main Results: There were 395 patients exhibiting favorable neurologic recovery (n = 357 in the early group, n = 38 in late group) and 134 patients exhibiting poor neurologic recovery (poor recovery group). Among patients who remained unconscious on day 7, delayed awakening was associated with male sex (odds ratio [OR], 3.905; 95% CI, 1.153-13.221), prehospital return of spontaneous circulation (OR, 7.628; 95% CI, 2.084-27.922), therapeutic hypothermia (OR, 4.320; 95% CI, 1.624-11.488), and extracorporeal cardiopulmonary resuscitation (OR, 4.508; 95% CI, 1.414-14.371). Being transferred from another hospital, however, was less likely to be associated with delayed awakening (OR, 0.061; 95% CI, 0.009-0.431). The median duration for patients to regain clear consciousness in the late recovery group was 12.12 days. No patient who recovered consciousness had an unfavorable electroencephalography pattern, however, in patients with poor recovery, the 7-day electroencephalography showed 45 patients with generalized suppression (33.6%), two with burst suppression (1.5%), 14 with seizure/epileptic discharge (10.5%), and one with status epilepticus (0.7%).Conclusions: Up to 9.6% of cardiac arrest patients with favorable outcomes recover consciousness after the recommended 7 days of observation, indicating the observation time of 7 days seems justified but longer duration may be needed. The results of the culturally and clinically isolated population may limit the application to other population. [ABSTRACT FROM AUTHOR]

Objectives: The optimal target temperature during targeted temperature management for patients after cardiac arrest remains under debate. The aim of this study was to evaluate the association between targeted temperature management at lower target temperatures and the neurologic outcomes among patients classified by the severity of postcardiac arrest syndrome.Design: A multicenter observational study from the out-of-hospital cardiac arrest registry of the Japanese Association for Acute Medicine, which is a nationwide prospective registry of out-of-hospital cardiac arrest patients.Setting: A total of 125 critical care medical centers or hospitals with an emergency care department across Japan.Patients: A total of 1,111 out-of-hospital cardiac arrest patients who had received targeted temperature management.Measurements and Main Results: We divided all 1,111 postcardiac arrest syndrome patients treated with targeted temperature management into two groups: those who received targeted temperature management at a lower target temperature (33-34°C) and those who received targeted temperature management at a higher target temperature (35-36°C). In regard to classification of the patients, we divided the patients into three categories of severity (low, moderate, and high severities) using the risk classification tool, post-Cardiac Arrest Syndrome for Therapeutic hypothermia, which was previously validated. The primary outcome was the percentage of patients with a good neurologic outcome at 30 days, and the secondary outcome was the survival rate at 30 days. Multivariate analysis showed that targeted temperature management at 33-34°C was significantly associated with a good neurologic outcome and survival at 30 days in the moderate severity (odds ratio, 1.70 [95% CI, 1.03-2.83] and 1.90 [95% CI, 1.15-3.16], respectively), but not in the patients of low or high severity (pinteraction = 0.033). Propensity score analysis also showed that targeted temperature management at 33-34°C was associated with a good neurologic outcome in the moderate-severity group (p = 0.022).Conclusions: Targeted temperature management at 33-34°C was associated with a significantly higher rate of a good neurologic outcome in the moderate-severity postcardiac arrest syndrome group, but not in the low- or high-severity group. [ABSTRACT FROM AUTHOR]

This article provides nurses with up-to-date evidence to empower them in contributing to the 33°C versus 36°C discussion in postcardiac arrest targeted temperature management (TTM). Presented in debate format, this article addresses the pros and cons of various target temperatures, examines the evidence around TTM, and applies it to clinical scenarios. [ABSTRACT FROM AUTHOR]

Objective: To determine the effects of adjunctive therapeutic hypothermia, by comparing hyperbaric oxygen therapy versus hyperbaric oxygen therapy combined with therapeutic hypothermia in acute severe carbon monoxide poisoning.Design: Retrospective analysis of data from our prospectively collected carbon monoxide poisoning registry.Setting: A single academic medical center in Wonju, Republic of Korea.Patients: Patients with acute severe carbon monoxide poisoning older than 18 years. Acute severe carbon monoxide poisoning was defined as mental status showing response to painful stimulus or unresponsive at the emergency department, and a continuation of this depressed mental status even after the first hyperbaric oxygen therapy. Patients were classified into the no-therapeutic hypothermia and therapeutic hypothermia groups. Hyperbaric oxygen therapy was performed up to twice within 24 hours after emergency department arrival, whereas therapeutic hypothermia was performed at a body temperature goal of 33°C for 24 hours using an endovascular cooling device after the first hyperbaric oxygen therapy.Interventions: Hyperbaric oxygen therapy versus hyperbaric oxygen therapy combined with therapeutic hypothermia.Measurements and Main Results: We investigated the difference in the Global Deterioration Scale score at 1 and 6 months after carbon monoxide exposure, between the no-therapeutic hypothermia and therapeutic hypothermia groups. Global Deterioration Scale scores were classified as follows: 1-3 points (favorable neurocognitive outcome) and 4-7 points (poor neurocognitive outcome). During the study period, 37 patients were treated for acute severe carbon monoxide poisoning, with 16 and 21 patients in the no-therapeutic hypothermia and therapeutic hypothermia groups, respectively. The therapeutic hypothermia group demonstrated significantly higher number of patients with favorable outcomes (p = 0.008) at 6 months after carbon monoxide exposure and better improvement of the 6-month Global Deterioration Scale score than the 1-month score (p = 0.006).Conclusions: Our data suggest that in acute severe carbon monoxide poisoning, patients who were treated using therapeutic hypothermia combined with hyperbaric oxygen therapy had significantly more favorable neurocognitive outcomes at 6 months after carbon monoxide exposure than those treated with hyperbaric oxygen therapy alone. [ABSTRACT FROM AUTHOR]

Background: Hypoxic-ischemic encephalopathy (HIE) remains devastating for neonates despite widespread treatment with therapeutic hypothermia (TH). The heart rate characteristic (HRC) index score, a measure of heart rate variability, could prove useful in the management of neonates with HIE as new therapies emerge or when withdrawal-of-support decisions are being considered.Purpose: The main purpose was to describe correlation between HRC index scores and brain magnetic resonance imaging (MRI) severity of injury for neonates with HIE.Methods/analysis: Low/high HRC index scores retrieved at initiation of TH (baseline), 24, 48, 72, and 96 hours, brain MRI severity of injury, and National Institute of Child Health and Human Development Death/Disability and Death scores were collected and analyzed retrospectively. Independent t tests and linear regression were used to examine relationships for each outcome measure.Results: Twenty-seven neonates were stratified into 2 groups: noninjury (n = 11) and injury (n = 16). Statistically significant relationships were observed. Strikingly, mean low HRC index score for the noninjury group ranged between 0.37 and 0.65 and was between 0.61 and 0.86 for the injury group. Mean high HRC index score for the noninjury group ranged between 0.66 and 1.02 and was between 1.04 and 1.41 for the injury group.Implications For Practice: HRC index score may be a useful guide in the future management of neonates with HIE.Implications For Research: This study established correlations between HRC index and MRI injury scores in neonates treated with TH. Further research is warranted to establish important relationships between brain injury and HRC index scores before this tool can be used clinically for this purpose. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the effect of the application of therapeutic hypothermia (32-35°C) on survival and major clinical endpoints in critically ill patients.Data Sources: We searched online database and clinical trial registries dated up to April 30, 2019, and references of relevant studies.Study Selection: Low risk of bias randomized trials which compared hypothermia applied for at least 24 hours and conventional therapy in critically ill patients were included. We excluded trials investigating therapeutic hypothermia in indications already supported by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns) or intraoperative hypothermia.Data Extraction: Titles and abstracts were reviewed independently by two authors. If the articles seemed eligible, full-text articles were reviewed, and data were abstracted using a structured template.Data Synthesis: Our search retained 14 low risk of bias randomized trials (2,670 patients) performed in three different settings: traumatic brain injury, serious infections, and stroke. Therapeutic hypothermia was associated with an increase in mortality at longest follow-up available (432/1,375 [31%] vs 330/1,295 [25%]; risk ratio, 1.24; 95% CI, 1.10-1.39; p = 0.0004; I = 0%). Pooled results showed no difference of good neurologic outcome among survivors between the two treatment arms (493/1,142 [43%] vs 486/1,067 [46%]; risk ratio, 1.04; 95% CI, 0.97-1.12; p = 0.27; I = 1%). Arrhythmias were significantly increased among patients undergoing therapeutic hypothermia. We found no difference between groups in pneumonia, serious infections, any infection, hemorrhage, renal failure, deep vein thrombosis, and uncontrollable intracranial hypertension.Conclusions: High-quality randomized evidence indicates that therapeutic hypothermia is associated with higher mortality and no difference in good neurologic outcome compared with normothermia in critically ill patients. Although there still might be a possibility that therapeutic hypothermia is beneficial in a specific setting, routine application of therapeutic hypothermia would better be avoided outside the settings indicated by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns). [ABSTRACT FROM AUTHOR]

Objectives: To determine the association between targeted temperature management goal temperature of 33°C versus 36°C and neurologic outcome after out-of-hospital cardiac arrest.Design: This was a retrospective, before-and-after, cohort study.Setting: Urban, academic, level 1 trauma center from 2010 to 2017.Patients: Adults with nontraumatic out-of-hospital cardiac arrest who received targeted temperature management.Interventions: Our primary exposure was targeted temperature management goal temperature, which was changed from 33°C to 36°C in April of 2014 at the study hospital. Primary outcome was neurologically intact survival to discharge. Secondary outcomes included hospital mortality and care processes.Measurements and Main Results: Of 782 out-of-hospital cardiac arrest patients transported to the study hospital, 453 (58%) received targeted temperature management. Of these, 258 (57%) were treated during the 33°C period (targeted temperature management 33°C) and 195 (43%) were treated during the 36°C period (targeted temperature management 36°C). Patients treated during targeted temperature management 33°C were older (57 vs 52 yr; p < 0.05) and had more arrests of cardiac etiology (45% vs 35%; p < 0.05), but otherwise had similar baseline characteristics, including initial cardiac rhythm. A total of 40% of patients treated during targeted temperature management 33°C survived with favorable neurologic outcome, compared with 30% in the targeted temperature management 36°C group (p < 0.05). After adjustment for demographic and cardiac arrest characteristics, targeted temperature management 33°C was associated with increased odds of neurologically intact survival to discharge (odds ratio, 1.79; 95% CI, 1.09-2.94). Targeted temperature management 33°C was not associated with significantly improved hospital mortality. Targeted temperature management was implemented faster (1.9 vs 3.5 hr from 911 call; p < 0.001) and more frequently in the emergency department during the targeted temperature management 33°C period (87% vs 55%; p < 0.001).Conclusions: Comatose, adult out-of-hospital cardiac arrest patients treated during the targeted temperature management 33°C period had higher odds of neurologically intact survival to hospital discharge compared with those treated during the targeted temperature management 36°C period. There was no significant difference in hospital mortality. [ABSTRACT FROM AUTHOR]

Background: Therapeutic hypothermia (TH) has shown promise for increasing survival and neurological recovery for post--cardiac arrest patients who are not responding neurologically initially after return of spontaneous circulation. Objective: The aim of this study was to explore the differences between surface and intravascular cooling methods of TH related to survival and neurological outcomes in post--cardiac arrest patients. Method: A literature search was conducted from 2008 to 2018 using 4 databases, including PubMed, CINAHL, Web of Science, and Scopus. Results: Six articles were identified that compared surface and intravascular cooling for TH in post--cardiac arrest patients, with the outcomes being mortality and neurological outcome. The articles included observational retrospective studies, a systematic analysis, and randomized controlled studies. The articles had between 167 and 934 participants from multiple locations, including Europe, Australia, France, Norway, the Netherlands, and South Korea. The analyzed literature did not highlight differences in mortality or neurological outcome when surface cooling or intravascular cooling was used in post--cardiac arrest patients. One study did find that intravascular cooling was superior to surface cooling in mortality and neurological outcome. Three studies showed better survival rates after intravascular cooling even if not statistically significant. Clinically, using either cooling method is acceptable. Discussion: This review found no difference between intravascular and surface cooling and effects on survival and neurological outcome. More research needs to be performed on the best type of cooling method as well as the best product within each category. [ABSTRACT FROM AUTHOR]

Chemotherapy-induced peripheral neuropathy (CIPN) is a severe adverse effect that occurs secondary to anticancer treatments and has no known preventive or therapeutic strategy. Therapeutic hypothermia has been shown to be effective in protecting against central and peripheral nervous system injuries. However, the effects of therapeutic hypothermia on CIPN have rarely been explored. We induced lower back hypothermia (LBH) in an established paclitaxel-induced CIPN rat model and found that the paclitaxel-induced impairments observed in behavioral, electrophysiological, and histological impairments were inhibited by LBH when applied at an optimal setting of 24°C to the sciatic nerve and initiated 90 minutes before paclitaxel infusion. Lower back hypothermia also inhibited the paclitaxel-induced activation of astroglia and microglia in the spinal cord and macrophage infiltration into and neuronal injury in the dorsal root ganglia and sciatic nerves. Furthermore, LBH decreased the local blood flow and local tissue concentrations of paclitaxel. Finally, in NOD/SCID mice inoculated with cancer cells, the antiproliferative effect of paclitaxel was not affected by the distal application of LBH. In conclusion, our findings indicate that early exposure to regional hypothermia alleviates paclitaxel-induced peripheral neuropathy. Therapeutic hypothermia may therefore represent an economical and nonpharmaceutical preventive strategy for CIPN in patients with localized solid tumors. [ABSTRACT FROM AUTHOR]

Background: Experimental trials suggest improved outcome by mild therapeutic hypothermia for cardiogenic shock after acute myocardial infarction. The objective of this study was to investigate the hemodynamic effects of mild therapeutic hypothermia in patients with cardiogenic shock complicating acute myocardial infarction.Methods: Patients (n=40) with cardiogenic shock undergoing primary percutaneous coronary intervention without classic indications for mild therapeutic hypothermia underwent randomization in a 1:1 fashion to mild therapeutic hypothermia for 24 hours or control. The primary end point was cardiac power index at 24 hours; secondary end points included other hemodynamic parameters and serial measurements of arterial lactate.Results: No relevant differences were observed for the primary end point of cardiac power index at 24 hours (mild therapeutic hypothermia versus control: 0.41 [interquartile range, 0.31-0.52] versus 0.36 [interquartile range, 0.31-0.48] W/m2; P=0.50; median difference, -0.025 W/m2; 95% CI, -0.12 to 0.06). Similarly, all other hemodynamic measurements were not statistically different. Arterial lactate levels at 6, 8, and 10 hours were significantly higher in patients in the mild therapeutic hypothermia group with a slower decline ( P for interaction=0.03). There were no differences in 30-day mortality (60% versus 50%; hazard ratio, 1.27; 95% CI, 0.55-2.94; P=0.55).Conclusions: In this randomized trial, mild therapeutic hypothermia failed to show a substantial beneficial effect on cardiac power index at 24 hours in patients with cardiogenic shock after acute myocardial infarction.Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01890317. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate knowledge translation after publication of the target temperature management 33°C versus 36°C after out-of-hospital cardiac arrest trial and associated patient outcomes. Our primary hypothesis was that target temperature management at 36°C was rapidly adopted in Australian and New Zealand ICUs. Secondary hypotheses were that temporal reductions in mortality would be seen and would have accelerated after publication of the target temperature management trial.Design: Retrospective cohort study (January 2005 to December 2016).Setting: The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation adult patient database containing greater than 2 million admission episodes from 186 Australian and New Zealand ICUs.Patients: Sixteen-thousand two-hundred fifty-two adults from 140 hospitals admitted to ICU after out-of-hospital cardiac arrest.Interventions: The primary exposure of interest was admission before versus after publication of the target temperature management trial.Measurements and Main Results: The primary outcome variable to evaluate changes in temperature management was lowest temperature in the first 24 hours in ICU. The primary clinical outcome variable of interest was inhospital mortality. Secondary outcomes included proportion of patients with fever in the first 24 hours in ICU. Mean ± SD lowest temperature in the first 24 hours in ICU in pre- and posttarget temperature management trial patients was 33.80 ± 1.71°C and 34.70 ± 1.39°C, respectively (absolute difference, 0.98°C [99% CI, 0.89-1.06°C]). Inhospital mortality rate decreased by 1.3 (99% CI, -1.8 to -0.9) percentage points per year from January 2005 until December 2013 and increased by 0.6 (99% CI, -1.4 to 2.6) percentage points per year from January 2014 until December 2016 (change in slope 1.9 percentage points per year [99% CI, -0.6 to 4.4]). Fever occurred in 568 (12.8%) of 4,450 pretarget temperature management trial patients and 853 (16.5%) of 5,184 posttarget temperature management trial patients (odds ratio, 1.35 [99% CI, 1.16-1.57]).Conclusions: The average lowest temperature of postcardiac arrest patients in the first 24 hours in ICU rose after publication of the target temperature management trial. This change was associated with an increased frequency of fever not seen in the target temperature management trial. [ABSTRACT FROM AUTHOR]

Objectives: Therapeutic hypothermia has been of topical interest for many years and with the publication of two international, multicenter randomized controlled trials, the evidence base now needs updating. The aim of this systematic review of randomized controlled trials is to assess the efficacy of therapeutic hypothermia in adult traumatic brain injury focusing on mortality, poor outcomes, and new pneumonia.Data Sources: The following databases were searched from January 1, 2011, to January 26, 2018: Cochrane Central Register of Controlled Trial, MEDLINE, PubMed, and EMBASE.Study Selection: Only foreign articles published in the English language were included. Only articles that were randomized controlled trials investigating adult traumatic brain injury sustained following an acute, closed head injury were included. Two authors independently assessed at each stage.Data Extraction: Quality was assessed using the Cochrane Collaboration's tool for assessing the risk of bias. All extracted data were combined using the Mantel-Haenszel estimator for pooled risk ratio with 95% CIs. p value of less than 0.05 was considered statistically significant. All statistical analyses were conducted using RevMan 5 (Cochrane Collaboration, Version 5.3, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).Data Synthesis: Twenty-two studies with 2,346 patients are included. Randomized controlled trials with a low risk of bias show significantly more mortality in the therapeutic hypothermia group (risk ratio, 1.37; 95% CI, 1.04-1.79; p = 0.02), whereas randomized controlled trials with a high risk of bias show the opposite with a higher mortality in the control group (risk ratio, 0.70; 95% CI, 0.60-0.82; p < 0.00001).Conclusions: Overall, this review is in-keeping with the conclusions published by the most recent randomized controlled trials. High-quality studies show no significant difference in mortality, poor outcomes, or new pneumonia. In addition, this review shows a place for fever control in the management of traumatic brain injury. [ABSTRACT FROM AUTHOR]

Therapeutic hypothermia, also referred to as targeted temperature management, has been a component of the postcardiac arrest treatment guidelines since 2010. Although almost a decade has passed since its inclusion in the postarrest guidelines, many unanswered questions remain regarding selection of the appropriate patient population, optimal target temperature, ideal window of time in which to initiate therapy after arrest, most efficient, safe, and accurate equipment choice for inducing and maintaining hypothermia, most effective duration of treatment, and rate of cooling or rewarming. On a national and international level, critical care nurses are in a unique position to participate in research that will define targeted temperature management protocols and practices. Nurses are also ideal for standardizing the targeted temperature management policy and protocol locally and nationally based on current available evidence. This review aims to serve 2 purposes: first, to provide a broad update on the current clarifications and limitations per research findings on target temperature management therapy; second, to explain how critical care nurses can use this updated information to improve outcomes for their patients with cardiac arrest. [ABSTRACT FROM AUTHOR]

Implementing evolving science into clinical practice remains challenging. Assimilating new scientific evidence into clinical protocols and best practice recommendations, in a timely manner, can be difficult. In this article, we examine the value of partnering with a captive medical malpractice insurance company and its Patient Safety Organization to use data and convening opportunities to build upon the principles of implementation science and foster efficient and widespread adoption of the most current evidence-based interventions. Analyses of medical malpractice and root-cause analysis data set the context for this partnership and acted as a catalyst for creating best practice guidelines for adopting therapeutic hypothermia in the treatment of neonatal encephalopathy. What follows is a powerful example of successfully leveraging the collective wisdom of healthcare providers across specialties and institutional lines to move patient safety forward while managing risk. [ABSTRACT FROM AUTHOR]

Objectives: The Eurotherm3235 trial showed that therapeutic hypothermia was deleterious in patients with raised intracranial pressure following traumatic brain injury. We sought to ascertain if increased temperature variability within the first 48 hours, or for 7 days post randomization, were modifiable risk factors associated with poorer outcome.Design: Eurotherm3235 was a multicenter randomized controlled trial. Patients were randomized to receive either therapeutic hypothermia in addition to standard care or the later only. Mean moving range (mr) was used to stratify subjects into tertiles by the variability present in their core temperature within the first 48 hours post randomization and within 7 days post randomization. The primary outcome measure was a collapsed Glasgow Outcome Scale-Extended at 6 months post randomization. The temperature variability effect was estimated with ordinal logistic regression adjusted for baseline covariates and treatment effect.Setting: Forty-seven critical care units in 18 countries.Patients: Patients enrolled in the Eurotherm3235 trial to either therapeutic hypothermia or control treatments only.Measurements and Main Results: Three hundred eighty-six patients were included in our study. High level of temperature variability during the first 48 hours was associated with poorer collapsed Glasgow Outcome Scale-Extended. This effect remained statistically significant when only the control arm of the study was analyzed. No statistically significant effect was seen within the first 48 hours in the hypothermia group or within 7 days in either group.Conclusions: When targeting normothermia, temperature variability may be a statistically significant variable in an ordinal analysis adjusted for baseline covariates. [ABSTRACT FROM AUTHOR]

More than 300,000 Americans suffer a cardiac arrest outside of the hospital each year and even among those who are successfully resuscitated and survive to hospital admission, outcomes remain poor. Temperature management (previously known as therapeutic hypothermia) is the only intervention that has been reproducibly demonstrated to ameliorate the neurologic injury that follows cardiac arrest. The results of a recent large randomized controlled trial have highlighted the uncertainty about temperature management strategies following cardiac arrest. This article reviews the issues and recommendations. [ABSTRACT FROM AUTHOR]

Background: Hospital-acquired pressure injuries (HAPIs) can be caused by multiple factors including pressure, shear, friction, moisture/incontinence, device-related pressure, immobility, inactivity, and nutritional deficits. Along with immobility, medical device-related (MDR) HAPIs are a primary cause of pressure injury in neonates, as the clinical practice setting has become increasingly technologically advanced. It is estimated that up to 50% of HAPIs are MDR in pediatric patients. Neonates are at particular risk for HAPI because of their specific anatomical, physiological, and developmental vulnerabilities. A specific example of confluent factors that may increase risk for HAPI is the application of therapeutic hypothermia (TH) and continuous electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy (HIE).Interventions: An interprofessional team collaborated to expand upon existing evidence-based standards of care to address the needs of this specific population within the neonatal intensive care unit (NICU). Interventions centered on revision of current protocols, with efforts to optimize product selection, hardwire assessment practices, and refine documentation of patient care and outcomes.Methods: The team primarily utilized plan-do-study-act (PDSA) cycles to test and refine specific methods and strategies to reduce HAPIs. Tested solutions were adopted, adapted, or abandoned.Results: A sustained zero HAPI rate in the HIE population resulted. The team continues to collect, report, and utilize near-miss data to continue to refine the process as new risks are identified.Implications For Practice: Recognizing the unique skin protection needs of special populations within the NICU, such as those undergoing TH, is crucial. When evidence-based standards of care fail to adequately meet such needs, a collaborative approach to identifying, testing, and implementing population-specific solutions is essential.Implications For Research: A paucity of literature regarding the unique skin protection needs for babies undergoing TH exists. Work should be done to better describe the influence of TH on skin integrity, with the goal of identifying population-specific protective measures. [ABSTRACT FROM AUTHOR]

Objectives: Prior studies suggest hypothermia may be beneficial in acute respiratory distress syndrome, but cooling causes shivering and increases metabolism. The objective of this study was to assess the feasibility of performing a randomized clinical trial of hypothermia in patients with acute respiratory distress syndrome receiving treatment with neuromuscular blockade because they cannot shiver.Design: Retrospective study and pilot, prospective, open-label, feasibility study.Setting: Medical ICU.Patients: Retrospective review of 58 patients with acute respiratory distress syndrome based on Berlin criteria and PaO2/FIO2 less than 150 who received neuromuscular blockade. Prospective hypothermia treatment in eight acute respiratory distress syndrome patients with PaO2/FIO2 less than 150 receiving neuromuscular blockade.Intervention: Cooling to 34-36°C for 48 hours.Measurements and Main Results: Core temperature, hemodynamics, serum glucose and electrolytes, and P/F were sequentially measured, and medians (interquartile ranges) presented, 28-day ventilator-free days, and hospital mortality were calculated in historical controls and eight cooled patients. Average patient core temperature was 36.7°C (36-37.3°C), and fever occurred during neuromuscular blockade in 30 of 58 retrospective patients. In the prospectively cooled patients, core temperature reached target range less than or equal to 4 hours of initiating cooling, remained less than 36°C for 92% of the 48 hours cooling period without adverse events, and was lower than the controls (34.35°C [34-34.8°C]; p < 0.0001). Compared with historical controls, the cooled patients tended to have lower hospital mortality (75% vs 53.4%; p = 0.26), more ventilator-free days (9 [0-21.5] vs 0 [0-12]; p = 0.16), and higher day 3 P/F (255 [160-270] vs 171 [120-214]; p = 0.024).Conclusions: Neuromuscular blockade alone does not cause hypothermia but allowed acute respiratory distress syndrome patients to be effectively cooled. Results support conducting a randomized clinical trial of hypothermia in acute respiratory distress syndrome and the feasibility of studying acute respiratory distress syndrome patients receiving neuromuscular blockade. [ABSTRACT FROM AUTHOR]

Objectives: Hypothermia reduces intracranial hypertension in patients with traumatic brain injury but was associated with harm in the Eurotherm3235Trial. We stratified trial patients by International Mission for Prognosis and Analysis of Clinical Trials in [Traumatic Brain Injury] (IMPACT) extended model sum scores to determine where the balance of risks lay with the intervention.Design: The Eurotherm3235Trial was a randomized controlled trial, with standardized and blinded outcome assessment. Patients in the trial were split into risk tertiles by IMPACT extended model sum scores. A proportional hazard analysis for death between randomization and 6 months was performed by intervention and IMPACT extended model sum scores tertiles in both the intention-to-treat and the per-protocol populations of the Eurotherm3235Trial.Setting: Forty-seven neurologic critical care units in 18 countries.Patients: Adult traumatic brain injury patients admitted to intensive care who had suffered a primary, closed traumatic brain injury; increased intracranial pressure; an initial head injury less than 10 days earlier; a core temperature at least 36°C; and an abnormal brain CT.Intervention: Titrated Hypothermia in the range 32-35°C as the primary intervention to reduce raised intracranial pressure.Measurements and Main Results: Three hundred eighty-six patients were available for analysis in the intention-to-treat and 257 in the per-protocol population. The proportional hazard analysis (intention-to-treat and per-protocol populations) showed that the treatment effect behaves similarly across all risk stratums. However, there is a trend that indicates that patients in the low-risk group could be at greater risk of suffering harm due to hypothermia.Conclusions: Hypothermia as a first line measure to reduce intracranial pressure to less than 20 mm Hg is harmful in patients with a lower severity of injury and no clear benefit exists in patients with more severe injuries. [ABSTRACT FROM AUTHOR]

Objective: Therapeutic hypothermia has been used to attenuate the effects of traumatic brain injuries. However, the required degree of hypothermia, length of its use, and its timing are uncertain. We undertook a comprehensive meta-analysis to quantify benefits of hypothermia therapy for traumatic brain injuries in adults and children by analyzing mortality rates, neurologic outcomes, and adverse effects.Data Sources: Electronic databases PubMed, Google Scholar, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov and manual searches of studies were conducted for relevant publications up until February 2016.Study Selection: Forty-one studies in adults (n = 3,109; age range, 18-81 yr) and eight studies in children (n = 454; age range, 3 mo to 18 yr) met eligibility criteria.Data Extraction: Baseline patient characteristics, enrollment time, methodology of cooling, target temperature, duration of hypothermia, and rewarming protocols were extracted.Data Synthesis: Risk ratios with 95% CIs were calculated. Compared with adults who were kept normothermic, those who underwent therapeutic hypothermia were associated with 18% reduction in mortality (risk ratio, 0.82; 95% CI, 0.70-0.96; p = 0.01) and a 35% improvement in neurologic outcome (risk ratio, 1.35; 95% CI, 1.18-1.54; p < 0.00001). The optimal management strategy for adult patients included cooling patients to a minimum of 33°C for 72 hours, followed by spontaneous, natural rewarming. In contrast, adverse outcomes were observed in children who underwent hypothermic treatment with a 66% increase in mortality (risk ratio, 1.66; 95% CI, 1.06-2.59; p = 0.03) and a marginal deterioration of neurologic outcome (risk ratio, 0.90; 95% CI, 0.80-1.01; p = 0.06).Conclusions: Therapeutic hypothermia is likely a beneficial treatment following traumatic brain injuries in adults but cannot be recommended in children. [ABSTRACT FROM AUTHOR]

Background: The traumatic experiences of parents of babies treated with therapeutic hypothermia (TH) have been described. No research has assessed neonatal intensive care unit (NICU) nurse experience in providing care to hypothermic babies and emotional support to their parents.Purpose: To assess NICU nurse attitudes to the provision of TH with respect to perceptions about baby pain/sedation, need for nurse and parent education, decision making about initiation of TH, and barriers to best care.Methods: A survey was electronically sent to 219 nurses at 2 affiliated academic level III NICUs: 1 rural and 1 urban location. There were 17 questions where responses were selected from a preset list and 7 opportunities for nurses to provide free text responses.Findings: The response rate was 38% (N = 83). Overwhelming similarities between the urban and rural institutions were found with NICU nurses expressing understanding of the indications for initiating TH, agreement that TH improves long-term outcomes and that the benefits of TH outweigh the risks. Nurses at the urban institution more frequently expressed concerns surrounding inadequate treatment of baby pain/sedation, and nurses at both institutions strongly emphasized the need for more nurse and parent education about TH and improved timeliness of decision making for initiation of TH.Implications For Practice: NICU nurses specifically want to learn more about outcomes of babies after treatment with TH and feel that parents need more education about TH.Implications For Research: Research is urgently needed to better understand the implications of TH treatment for parent-baby bonding. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Intrapartum cesarean deliveries (CDs) are associated with higher rates of maternal and neonatal morbidity than scheduled CDs. In patients undergoing trial of labor after cesarean (TOLAC), perceived added difficulty of intrapartum CD may influence provider decisions on labor management. We sought to evaluate the effect of prior CD on operative times and maternal/neonatal outcomes among those undergoing intrapartum CD. METHODS: This is a retrospective cohort study of all singleton, nonanomalous fetuses delivered by intrapartum CD at a tertiary care center from June 2018 to April 2019. CD was categorized as intrapartum if it occurred after the patient was admitted in spontaneous labor or received an induction agent. The primary outcome was time from skin incision to delivery. Secondary outcomes were composite measures of maternal (postpartum hemorrhage, bowel or bladder injury, transfusion, endomyometritis, intensive care unit admission, readmission, wound complications) and neonatal (neonatal intensive care unit admission, respiratory support, therapeutic hypothermia, neonatal mortality, and fetal acidemia) morbidity. We compared these outcomes between women with and without history of prior CD. Multivariable logistic regression was used to control for potential confounders. RESULTS: Of 374 intrapartum CDs, 270 (72%) were in patients without prior cesarean section and 104 (28%) were in patients undergoing TOLAC. Operative times were significantly longer in women with a prior CD including time from skin incision to delivery (9 [interquartile range (IQR) 7–13] versus 6 minutes [IQR 3–8], P <.001) and total procedure time (63 [IQR 52–79] versus 55 minutes [IQR 45–65], P <.001). Composite maternal (adjusted relative risk [aRR] 1.04, 95% CI 0.62–1.74) and neonatal (aRR 1.01, 95% CI 0.63–1.64) morbidity did not differ between groups. CONCLUSION: Although associated with longer operative times, history of a prior CD does not significantly increase maternal or neonatal morbidity among women undergoing intrapartum CD. Therefore, the threshold to perform an intrapartum CD in those undergoing TOLAC should be similar to those without a prior CD. [ABSTRACT FROM AUTHOR]

The article discusses the several clinical studies and experiments conducted by notable people in medicine including scientist Aristotle and surgeon Baron Dominique-Jean Larrey towards understanding of brain, hypothermia and temperature management. Topics include the targeted temperature management in modern era, the areas of investigation for therapeutic hypothermia in neocritical care and the association of fever in causing detrimental effect to brain injury.

Therapeutic hypothermia (TH) postresuscitation has been recommended by the American Heart Association (AHA) since 2005. Early initiation of TH and fast achievement of goal temperatures have been associated with better neurological outcomes. The objective of this study was to evaluate the effectiveness of a specific TH protocol for the emergency department (ED) in increasing ED use of TH and decreasing the time from return of spontaneous circulation (ROSC) to initiation of cooling measures. An ED protocol for TH as recommended by the AHA was implemented. A random sample of 10 patients who received TH prior to the implementation of an ED protocol were analyzed and compared with the first 10 patients who received TH after the ED protocol was implemented. The time from ROSC to initiation of cooling measures and survival to discharge rates were analyzed. After implementation of the ED protocol, 7 of the 10 patients were treated with the ED protocol. The mean time to initiation of TH for the preimplementation group was 127.8 min (SD = 52.9) compared with 15.71 min (SD = 9.552) for the postimplementation group. The difference in initiation time between the pre- and postimplementation study groups was statistically significant, t(9.826) = 6.55, p < 0.05. Survival to discharge rates were 30% for the preimplementation group and 20% for the postimplementation group. The difference was not statistically significant, χ² (1, N = 20) = 0.73, p = 0.78. Implementation of an ED protocol for TH reduced mean time to initiation of therapy. Additional study is warranted to determine whether differences in survival and functional recovery for ED patients receiving TH were influenced by age, comorbidities, and total resuscitation time. [ABSTRACT FROM AUTHOR]

Objectives: Atrial fibrillation has been associated with increased mortality in the general population and mixed populations of critical ill. Atrial fibrillation can also affect patients during post-cardiac arrest care. We sought to assess the prognostic implications of atrial fibrillation following out-of-hospital cardiac arrest, including relation to the level of targeted temperature management.Design: A post hoc analysis of a prospective randomized trial.Setting: Thirty-six ICUs.Patients: We included 897 (96%) of the 939 comatose out-of-hospital cardiac arrest survivors from the targeted temperature management trial (year, 2010-2013) with data on heart rhythm on day 2.Interventions: Targeted temperature management at 33°C or 36°C.Measurements and Main Results: Endpoints included cumulative proportion of atrial fibrillation following out-of-hospital cardiac arrest and 180-day all-cause mortality and specific death causes stratified by atrial fibrillation. Atrial fibrillation on day 2 was used as primary endpoint analyses to exclude effects of short-term atrial fibrillation related to resuscitation and initial management. The cumulative proportions of atrial fibrillation were 15% and 11% on days 1 and 2, respectively. Forty-three percent of patients with initial atrial fibrillation the first day were reported with sinus rhythm on day 2. No difference was found between the groups treated with targeted temperature management at 33°C and 36°C. Patients affected by atrial fibrillation had significantly higher 180-day mortality (atrial fibrillation: 66% vs no-atrial fibrillation: 43%; plogrank < 0.0001 and unadjusted hazard ratio, 1.75 [1.35-2.30]; p < 0.0001). The association between atrial fibrillation and higher mortality remained significant (adjusted hazard ratio, 1.34 [1.01-1.79]; p < 0.05) adjusted for potential confounders. Atrial fibrillation was independently associated with increased risk of cardiovascular death and multiple-organ failure (adjusted hazard ratio, 2.07 [1.39-3.09]; p < 0.001), whereas no association with higher risk of death from cerebral causes was found.Conclusions: Atrial fibrillation was independently associated with higher mortality, primarily driven by cardiovascular causes and multiple-organ failure, and may thus identify a vulnerable subpopulation. Whether treatment to prevent atrial fibrillation is associated with an improved prognosis remains to be established. [ABSTRACT FROM AUTHOR]

Objective: To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient."Design: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions.Results: The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death. [ABSTRACT FROM AUTHOR]

Background: Patients successfully resuscitated by paramedics from out-of-hospital cardiac arrest often have severe neurologic injury. Laboratory and observational clinical reports have suggested that induction of therapeutic hypothermia during cardiopulmonary resuscitation (CPR) may improve neurologic outcomes. One technique for induction of mild therapeutic hypothermia during CPR is a rapid infusion of large-volume cold crystalloid fluid.Methods: In this multicenter, randomized, controlled trial we assigned adults with out-of-hospital cardiac arrest undergoing CPR to either a rapid intravenous infusion of up to 2 L of cold saline or standard care. The primary outcome measure was survival at hospital discharge; secondary end points included return of a spontaneous circulation. The trial was closed early (at 48% recruitment target) due to changes in temperature management at major receiving hospitals.Results: A total of 1198 patients were assigned to either therapeutic hypothermia during CPR (618 patients) or standard prehospital care (580 patients). Patients allocated to therapeutic hypothermia received a mean (SD) of 1193 (647) mL cold saline. For patients with an initial shockable cardiac rhythm, there was a decrease in the rate of return of a spontaneous circulation in patients who received cold saline compared with standard care (41.2% compared with 50.6%, P=0.03). Overall 10.2% of patients allocated to therapeutic hypothermia during CPR were alive at hospital discharge compared with 11.4% who received standard care (P=0.71).Conclusions: In adults with out-of-hospital cardiac arrest, induction of mild therapeutic hypothermia using a rapid infusion of large-volume, intravenous cold saline during CPR may decrease the rate of return of a spontaneous circulation in patients with an initial shockable rhythm and produced no trend toward improved outcomes at hospital discharge.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01173393. [ABSTRACT FROM AUTHOR]

Background: Targeted temperature management (TTM) is a strategy used by critical care nurses to mitigate negative effects of out-of-hospital cardiac arrest (OHCA); however, integration and compliance of TTM protocols into routine clinical practice can be challenging. Objectives: The aims of this study are to (1) investigate the effects of initial TTM protocol implementation on patient mortality, length of stay, and discharge disposition among patients who experience OHCA and (2) evaluate initial compliance and potential barriers to newly implemented TTM protocol. Methods: A retrospective cohort design was used. Data were gathered on adult patients experiencing OHCA before and after immediate implementation of a TTM protocol within a large academic public hospital. Demographic and clinical data were abstracted from medical records of both TTM and non-TTM groups. Additional compliance data were gathered on the TTM group. Outcome variables included hospital mortality, length of stay, and discharge disposition. Results: Total accrual was 259. Mortality decreased after protocol implementation (89.4%, 75%, P G .05), which was supported in the regression analyses (P = .05; odds ratio, 2.8). A higher proportion of subjects were discharged home after the TTM protocol (21.5% discharged home after protocol implementation vs 5.1% discharged home before protocol implementation; P G .05). Full protocol compliance was 30%. Protocol documentation was inconsistent across units and personnel. Conclusions: Findings suggest that even initial implementation of TTM protocols can result in positive patient outcomes. Full compliance with protocols remains difficult. Critical care nurses are integral to initiation of and adherence to therapeutic hypothermia protocols and are in a key position to develop strategies for improved compliance across departments. [ABSTRACT FROM AUTHOR]

Given this and the adverse effects of fever, we aimed to establish the incidence of post arrest fever (Tmax >=38oC) when a cooling device was not used and impact on outcome. B Introduction: b In the wake of TTM2 many clinicians have replaced therapeutic hypothermia using a cooling device with fever avoidance (sometimes without a cooling device) in post-cardiac arrest patients. [Extracted from the article]

The institutional protocol utilized a morphine-based regimen for shivering and agitation prior to April 2020, and was modified to utilize a clonidine-based regimen afterwards, thus patients were grouped into morphine and clonidine epochs. The purpose of this study was to evaluate the perceived efficacy and safety of using a clonidine-based versus morphine-based sedation and shivering management strategy during TH. B Introduction: b Therapeutic hypothermia (TH) to core temperature of 33-34°C is standard of care to treat hypoxic ischemic encephalopathy (HIE) in neonates. [Extracted from the article]

B Methods: b Single-center retrospective chart review of post-cardiac arrest adult patients receiving intermediate or full intensity therapeutic nomogram IVUH with anti-Xa monitoring during TH. B Conclusions: b Standardized full intensity IVUH nomogram dosing with anti-Xa monitoring overestimates heparin requirements during TH. A significant difference was seen in median anti-Xa levels during TH compared to 24-hours after rewarming in both the intermediate intensity IVUH nomogram group (0.33 vs. 0.25, p=0.0015) and the full intensity IVUH nomogram group (0.70 vs. 0.28, p< 0.001). [Extracted from the article]

Objectives: To evaluate the change in provision of therapeutic hypothermia and coronary intervention (postresuscitation care) over time and to clarify the association between these provisions and in-hospital mortality in patients with out-of-hospital cardiac arrest.Design: A nationwide retrospective cohort study using multiple propensity score analyses.Setting: Japanese Diagnosis Procedure Combination inpatient database.Patients: Adult patients with cardiogenic out-of-hospital cardiac arrest related to ventricular fibrillation were identified from July to December in 2008-2012 (385 hospitals; n = 3,413).Measurements and Main Results: We evaluated the proportion of patients receiving postresuscitation care and all-cause mortality at 30 days after out-of-hospital cardiac arrest. The proportion of postresuscitation care provision increased significantly over the study period (Mantel-Haenszel trend test, p < 0.001). The overall 30-day mortality was 52.0% (1,774/3,413), and the crude 30-day mortality decreased significantly during the study period (p = 0.006). Logistic regression analysis showed significant associations between the fiscal years 2011 and 2012 and 30-day mortality (2011: odds ratio, 0.75; 95% CI, 0.57-0.98 and 2012: odds ratio, 0.61; 95% CI, 0.47-0.81). Multiple propensity score analysis incorporating postresuscitation care showed that 30-day mortality was significantly associated with postresuscitation care, and the significant associations between 30-day mortality and the years 2011 and 2012 were no longer observed (2011: odds ratio, 1.05; 95% CI, 0.82-1.3 and 2012: odds ratio, 0.95; 95% CI, 0.74-1.2).Conclusions: The 30-day survival rate of adult patients with cardiogenic out-of-hospital cardiac arrest related to ventricular fibrillation improved significantly after 2010 in Japan. This improvement may be associated with an increase in postresuscitation care provision. [ABSTRACT FROM AUTHOR]

Objectives: Bradycardia is common during targeted temperature management, likely being a physiologic response to lower body temperature, and has recently been associated with favorable outcome following out-of-hospital cardiac arrest in smaller observational studies. The present study sought to confirm this finding in a large multicenter cohort of patients treated with targeted temperature management at 33°C and explore the response to targeted temperature management targeting 36°C.Design: Post hoc analysis of a prospective randomized study.Setting: Thirty-six ICUs in 10 countries.Patients: We studied 447 (targeted temperature management = 33°C) and 430 (targeted temperature management = 36°C) comatose out-of-hospital cardiac arrest patients with available heart rate data, randomly assigned in the targeted temperature management trial from 2010 to 2013.Interventions: Targeted temperature management at 33°C and 36°C.Measurements and Main Results: Endpoints were 180-day mortality and unfavorable neurologic function (cerebral performance category 3-5). Patients were stratified by target temperature and minimum heart rate during targeted temperature management (< 50, 50-59, and ≥ 60 beats/min [reference]) at 12, 20, and 28 hours after randomization. Heart rates less than 50 beats/min and 50-59 beats/min were recorded in 132 (30%) and 131 (29%) of the 33°C group, respectively. Crude 180-day mortality increased with increasing minimum heart rate (< 50 beats/min = 32%, 50-59 beats/min = 43%, and ≥ 60 beats/min = 60%; p(log-rank) < 0.0001). Bradycardia less than 50 beats/min was independently associated with lower 180-day mortality (hazard ratio(adjusted) = 0.50 [0.34-0.74; p < 0.001]) and lower odds of unfavorable neurologic outcome (odds ratio(adjusted) = 0.38 [ 0.21-0.68; p < 0.01]) in models adjusting for potential confounders including age, initial rhythm, time to return of spontaneous circulation, and lactate at admission. Similar, albeit less strong, independent associations of lower heart rates and favorable outcome were found in patients treated with targeted temperature management at 36°C.Conclusions: This study confirms an independent association of bradycardia and lower mortality and favorable neurologic outcome in a large cohort of comatose out-of-hospital cardiac arrest patients treated by targeted temperature management at 33°C. Bradycardia during targeted temperature management at 33°C may thus be a novel, early marker of favorable outcome. [ABSTRACT FROM AUTHOR]

Background: Therapeutic hypothermia (TH) attenuates reperfusion injury in comatose survivors of cardiac arrest. The utility of TH in patients with nonshockable initial rhythms has not been widely accepted. We sought to determine whether TH improved neurological outcome and survival in postarrest patients with nonshockable rhythms.Methods and Results: We identified 519 patients after in- and out-of-hospital cardiac arrest with nonshockable initial rhythms from the Penn Alliance for Therapeutic Hypothermia (PATH) registry between 2000 and 2013. Propensity score matching was used. Patient and arrest characteristics used to estimate the propensity to receive TH were age, sex, location of arrest, witnessed arrest, and duration of arrest. To determine the association between TH and outcomes, we created 2 multivariable logistic models controlling for confounders. Of 201 propensity score-matched pairs, mean age was 63 ± 17 years, 51% were male, and 60% had an initial rhythm of pulseless electric activity. Survival to hospital discharge was greater in patients who received TH (17.6% versus 28.9%; P < 0.01), as was a discharge Cerebral Performance Category of 1 to 2 (13.7% versus 21.4%; P = 0.04). In adjusted analyses, patients who received TH were more likely to survive (odds ratio, 2.8; 95% confidence interval, 1.6-4.7) and to have better neurological outcome (odds ratio, 3.5; 95% confidence interval, 1.8-6.6) than those that did not receive TH.Conclusions: Using propensity score matching, we found that patients with nonshockable initial rhythms treated with TH had better survival and neurological outcome at hospital discharge than those who did not receive TH. Our findings further support the use of TH in patients with initial nonshockable arrest rhythms. [ABSTRACT FROM AUTHOR]

Objective: To synthesize an emerging body of literature describing pharmacokinetic alterations and related pharmacodynamic implications affecting drugs commonly used in patients receiving targeted temperature management following cardiac arrest.Data Sources: Peer-reviewed articles indexed in PubMed.Study Selection: A systematic search of the PubMed database for relevant preclinical studies and clinical and observational trials of physiologic changes and drug pharmacokinetic and pharmacodynamic alterations, especially during targeted temperature management/therapeutic hypothermia, but also from cardiac surgery and acute stroke hypothermia models.Data Extraction: Detailed review of information contained in published scientific work.Data Synthesis: Physiologic changes during targeted temperature management significantly alter both the pharmacokinetic and the pharmacodynamic parameters of medications. Current literature describes these alterations and provides practical considerations for management of medications. Medication selection should center on the pharmacokinetics and pharmacodynamics of agents in an attempt to ameliorate potential adverse effects.Conclusions: This review provides an overview of physiologic changes associated with targeted temperature management and practical considerations for the management of medications. Clinicians should understand and anticipate potential drug-therapy interactions of targeted temperature management and mitigate adverse outcomes by appropriate medication selection, dosing, and monitoring. We discuss complications of hypothermia including shivering, electrolyte abnormalities, hemodynamic changes, arrhythmias, and seizures. We review management of these complications as well as considerations for sedation, analgesia, anticoagulation, and prognostication. Approach to interpretation of the clinical significance of drug interactions during targeted temperature management therapy is also addressed. [ABSTRACT FROM AUTHOR]

Background--Whether to perform or not an immediate percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest is still debated. We aimed to evaluate the impact of PCI on short- and long-term survival in out-of-hospital cardiac arrest patients admitted after successful resuscitation. Methods and Results--Between 2000 and 2013, all nontrauma out-of-hospital cardiac arrest patients admitted in a Parisian cardiac arrest center after return of spontaneous circulation were prospectively included. The association between immediate PCI and short- and long-term mortality was analyzed using logistic regression and Cox multivariate analysis, respectively. Propensity score-matching method was used to assess the influence of PCI on short- and long-term survival. During the study period, 1722 patients (71.5% male, median age 60 [49.6, 72.2] years) were analyzed: 628 (35.6%) without coronary angiography, 615 (35.7%) with coronary angiography without PCI, and 479 (27.8%) with both. Among these groups, day 30 and year-10 survival rates were 21% and 11.9%, 35% and 29%, 43% and 38%, respectively (P<0.01 for each). PCI as compared with no coronary angiography was associated with a lower day-30 and long-term mortality (adjORcoro with PCI versus no coro 0.71, 95% confidence interval [0.54, 0.92]; P=0.02 and adjHRcoro with PCI versus no coro 0.44, 95% confidence interval [0.27, 0.71]; P<0.01, respectively). PCI remained associated with a lower risk of long-term mortality (adjHR 0.29; 95% confidence interval [0.14, 0.61]; P<0.01) in propensity score-matching analysis. Conclusions--Immediate PCI after out-of-hospital cardiac arrest was associated with significant reduced risk of short- and longterm mortality. These findings should suggest physicians to consider immediate coronary angiography and PCI if indicated in these patients. [ABSTRACT FROM AUTHOR]

Objectives: To perform a pilot study to assess the feasibility of performing a phase III trial of therapeutic hypothermia started early and continued for at least 72 hours in children with severe traumatic brain injury. Design: Multicenter prospective randomized controlled phase II trial. Setting: All eight of the PICUs in Australia and New Zealand and one in Canada. Patients: Children 1-15 years old with severe traumatic brain injury and who could be randomized within 6 hours of injury. Interventions: The control group had strict normothermia to a temperature of 36-37°C for 72 hours. The intervention group had therapeutic hypothermia to a temperature of 32-33°C for 72 hours followed by slow rewarming at a rate compatible with maintaining intracranial pressure and cerebral perfusion pressure. Measurements and Main Results: Of 764 children admitted to PICU with traumatic brain injury, 92 (12%) were eligible and 55 (7.2%) were recruited. There were five major protocol violations (9%): three related to recruitment and consent processes and two to incorrect temperature management. Rewarming took a median of 21.5 hours (16-35 hr) and was performed without compromise in the cerebral perfusion pressure. There was no increase in any complications, including infections, bleeding, and arrhythmias. There was no difference in outcomes 12 months after injury; in the therapeutic hypothermia group, four (17%) had a bad outcome (pediatric cerebral performance category, 4-6) and three (13%) died, whereas in the normothermia group, three (12%) had a bad outcome and one (4%) died. Conclusions: Early therapeutic hypothermia in children with severe traumatic brain injury does not improve outcome and should not be used outside a clinical trial. Recruitment rates were lower and outcomes were better than expected. Conventional randomized controlled trials in children with severe traumatic brain injury are unlikely to be feasible. A large international trials group and alternative approaches to trial design will be required to further inform practice. [ABSTRACT FROM AUTHOR]

Since the Institute of Medicine's landmark report To Err Is Human, extensive efforts to improve patient safety have been undertaken. However, wide-scale improvement has been limited, sporadic, and inconsistent. Implementation of evidence-based interventions remains a challenge, resulting in unwarranted variations in care. Three main categories of problems in healthcare delivery are defined as overuse, underuse, and misuse of medical services, resulting in inappropriate care, inefficiencies, and poor quality. Although broad acknowledgement that these categories of quality problems exist, there are limited standards for measuring their overall impact. This article aims to discuss the important role of implementation science in advancing evidencebased practice, using neonatal therapeutic hypothermia for the treatment of hypoxic-ischemic encephalopathy as an exemplar for examining appropriateness of care. [ABSTRACT FROM AUTHOR]

Study Design. Animal study. Objective. To further investigate the effects of therapeutic hypothermia (TH), the present study compared autophagy and apoptosis after treatment with either therapeutic moderate systemic hypothermia or methylprednisolone sodium succinate (MP) in a rat model of acute spinal cord injury (SCI). Summary of Background Data. The neuroprotective effects of TH have recently become an important topic in the fi eld of SCI research. Methods. All rats were subjected to a 25-g/cm spinal cord contusion over the ninth thoracic vertebrae. After the induction of SCI, the control group did not receive any further treatment, TH group immediately received moderate systemic hypothermia for 4 hours, and MP group was administered high-dose MP. The rats were killed either 2 or 7 days after SCI, and the injured spinal cord tissues were obtained. Apoptosis and autophagy were assessed by immunohistochemical analyses and Western blot analyses. In addition, the microarchitecture of the autophagosomes was evaluated using transmission electron microscopy, and the motor activity of the rats was assessed using the Basso-Beattie-Bresnahan (BBB) locomotor rating scale. Results. Compared with controls, there was a signifi cant reduction in the expression levels of cleaved caspase-8, -9, and -3 in the THand MP-treated groups 2 days after SCI. Moreover, compared with the control group, the expression of LC3II and Beclin-1 exhibited a signifi cant decrease on day 2 after treatment with TH. The numbers of transferase dUTP nicked-end labeling and LC3-positive cells were signifi cantly lower on days 2 and 7. The Basso-Beattie-Bresnahan ratings were signifi cantly higher 6 weeks after SCI in both the TH-and MP-treated groups than in the control group. Conclusion. Both TH and MP have neuroprotective effects on injured spinal cord tissues via the inhibition of apoptosis and autophagy. Thus, the application of moderate systemic hypothermia may be a useful treatment modality after acute SCI. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the outcomes of cardiac arrest survivors with myoclonus receiving modern postresuscitation care. Design: Retrospective review of registry data. Setting: Cardiac arrest receiving centers in Europe and the United States from 2002 to 2012. Patients: Two thousand five hundred thirty-two cardiac arrest survivors 18 years or older enrolled in the International Cardiac Arrest Registry. Interventions: None. Measurements and Main Results: Eighty-eight percent of patients underwent therapeutic hypothermia and 471 (18%) exhibited myoclonus. Patients with myoclonus had longer time to professional cardiopulmonary resuscitation (8.6 vs 7.0 min; p < 0.001) and total ischemic time (25.6 vs 22.3 min; p < 0.001) and less often presented with ventricular tachycardia/ventricular fibrillation, a witnessed arrest, or had bystander cardiopulmonary resuscitation. Electroencephalography demonstrated myoclonus with epileptiform activity in 209 of 374 (55%), including status epilepticus in 102 of 374 (27%). Good outcome (Cerebral Performance Category 1-2) at hospital discharge was noted in 9% of patients with myoclonus, less frequently in myoclonus with epileptiform activity (2% vs 15%; p < 0.001). Patients with myoclonus with good outcome were younger (53.7 vs 62.7 yr; p < 0.001), had more ventricular tachycardia/ventricular fibrillation (81% vs 46%; p < 0.001), shorter ischemic time (18.9 vs 26.4 min; p = 0.003), more witnessed arrests (91% vs 77%; p = 0.02), and fewer "do-not- resuscitate" orders (7% vs 78%; p < 0.001). Life support was withdrawn in 330 of 427 patients (78%) with myoclonus and poor outcome, due to neurological futility in 293 of 330 (89%), at 5 days (3-8 d) after resuscitation. With myoclonus and good outcome, median ICU length of stay was 8 days (5-11 d) and hospital length of stay was 14.5 days (9-22 d). Conclusions: Nine percent of cardiac arrest survivors with myoclonus after cardiac arrest had good functional outcomes, usually in patients without associated epileptiform activity and after prolonged hospitalization. Deaths occurred early and primarily after withdrawal of life support. It is uncertain whether prolonged care would yield a higher percentage of good outcomes, but myoclonus of itself should not be considered a sign of futility. [ABSTRACT FROM AUTHOR]

Rationale: International guidelines recommend use of targeted temperature management following resuscitation from out-of-hospital cardiac arrest. This treatment, however, is often neglected or delayed. Objective: To determine whether multifaceted quality improvement interventions would increase the proportion of eligible patients receiving successful targeted temperature management. Setting: A network of 6 regional emergency medical services systems and 32 academic and community hospitals serving a population of 8.8 million people providing post arrest care to out-of- hospital cardiac arrest. Interventions: Comparing interventions improve the implementation of targeted temperature management post out-of-hospital cardiac arrest through passive (education, generic protocol, order set, local champions) versus additional active quality improvement interventions (nurse specialist providing site-specific interventions, monthly audit-feedback, network educational events, internet blog) versus no intervention (baseline standard of care). Measurements and Main Results: The primary process outcome was proportion of eligible patients receiving successful targeted temperature management, defined as a target temperature of 32-34°C within 6 hours of emergency department arrival. Secondary clinical outcomes included survival and neurological outcome at hospital discharge. Four thousand three hundred seventeen out-of-hospital cardiac arrests were transported to hospital; 1,737 (40%) achieved spontaneous circulation, and 934 (22%) were eligible for targeted temperature management. After accounting for secular trends, patients admitted during the passive quality improvement phase were more likely to achieve successful targeted temperature management compared with those admitted during the baseline period (25.7% passive vs 9.0% baseline; odds ratio, 2.76; 95% CI, 1.76-4.32; p < 0.001). Active quality improvement interventions conferred no additional improvements in rates of successful targeted temperature management (26.9% active vs 25.7% passive; odds ratio, 0.96; 95% CI, 0.63-1.45; p = 0.84). Despite a significant increase in rates of successful targeted temperature management, survival to hospital discharge was unchanged. Conclusion: Simple quality improvement interventions significantly increased the rates of achieving successful targeted temperature management following out-of-hospital cardiac arrest in a large network of hospitals but did not improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess the effect of sodium nitroprusside-enhanced cardiopulmonary resuscitation on heat exchange during surface cooling. We hypothesized that sodium nitroprusside- enhanced cardiopulmonary resuscitation would decrease the time required to reach brain temperature less than 35°C compared to active compression-decompression plus impedance threshold device cardiopulmonary resuscitation alone, in the setting of intra-cardiopulmonary resuscitation cooling. We further hypothesized that the addition of epinephrine during sodium nitroprusside-enhanced cardiopulmonary resuscitation would mitigate heat exchange. Design: Prospective randomized animal investigation. Setting: Preclinical animal laboratory. Subjects: Female farm pigs (n = 28). Interventions: After 10 minutes of untreated ventricular fibrillation, animals were randomized to three different protocols: sodium nitroprusside-enhanced cardiopulmonary resuscitation (n = 8), sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine (n = 10), and active compression-decompression plus impedance threshold device alone (control, n = 10). All animals received surface cooling at the initiation of cardiopulmonary resuscitation. Sodium nitroprusside-enhanced cardiopulmonary resuscitation included active compression-decompression plus impedance threshold device plus abdominal binding and 2 mg of sodium nitroprusside at 1, 4, and 8 minutes of cardiopulmonary resuscitation. No epinephrine was used during cardiopulmonary resuscitation in the sodium nitroprusside-enhanced cardiopulmonary resuscitation group. Control and sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine groups received 0.5 mg of epinephrine at 4.5 and 9 minutes of cardiopulmonary resuscitation. Defibrillation occurred after 10 minutes of cardiopulmonary resuscitation. After return of spontaneous circulation, an Arctic Sun (Medivance, Louiseville, CO) was applied at maximum cooling on all animals. The primary endpoint was the time required to reach brain temperature less than 35°C beginning from the time of cardiopulmonary resuscitation initiation. Data are presented as mean ± sem. Measurements and Main Results: The time required to reach a brain temperature of 35°C was decreased with sodium nitroprusside-enhanced cardiopulmonary resuscitation versus control or sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine (24 ± 6 min, 63 ± 8 min, and 50 ± 9 min, respectively; p = 0.005). Carotid blood flow was higher during cardiopulmonary resuscitation in the sodium nitroprusside- enhanced cardiopulmonary resuscitation group (83 ± 15 mL/min vs 26 ± 7 mL/min and 35 ± 5 mL/min in the control and sodium nitroprusside-enhanced cardiopulmonary resuscitation plus epinephrine groups, respectively; p = 0.001). Conclusions: This study demonstrates that sodium nitroprusside-enhanced cardiopulmonary resuscitation facilitates intra-cardiopulmonary resuscitation hypothermia. The addition of epinephrine to sodium nitroprusside-enhanced cardiopulmonary resuscitation during cardiopulmonary resuscitation reduced its improvement in heat exchange. [ABSTRACT FROM AUTHOR]

The article offers information on therapeutic temperature management (TTM) hypothermia after in-hospital cardiac arrest (CA). Topics discussed include studies by Nielsen and coworkers on the outcomes in patients with CA; guidelines of American Heart Association on the choosing the target core temperature; and percentage of patients with in-hospital CA treated with TTM.