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Hypoxic-ischaemic encephalopathy (HIE) is a severe complication of asphyxia at birth. Therapeutic hypothermia, the standard method for HIE prevention, is effective in only 50% of the cases. As the understanding of the immunological basis of these changes increases, experiments have begun with the use of cord blood (CB) because of its neuroprotective properties. Mechanisms for the neuroprotective effects of CB stem cells include antiapoptotic and anti-inflammatory actions, stimulation of angiogenesis, production of trophic factors, and mitochondrial donation. In several animal models of HIE, CB decreased oxidative stress, cell death markers, CD4+ T cell infiltration, and microglial activation; restored normal brain metabolic activity; promoted neurogenesis; improved myelination; and increased the proportion of mature oligodendrocytes, neuron numbers in the motor cortex and somatosensory cortex, and brain weight. These observations translate into motor strength, limb function, gait, and cognitive function and behaviour. In humans, the efficacy and safety of CB administration were reported in a few early clinical studies which confirmed the feasibility and safety of this intervention for up to 10 years. The results of these studies showed an improvement in the developmental outcomes over hypothermia. Two phase-2 clinical studies are ongoing under the United States regulations, namely one controlled study and one blinded study. [ABSTRACT FROM AUTHOR]

The outcome after out‐of‐hospital cardiac arrest has historically been grim at best. The current overall survival rate of patients admitted to a hospital is approximately 10%, making cardiac arrest one of the leading causes of death in the United States. The situation is improving with the incorporation of therapeutic temperature modulation, aggressive prevention of secondary brain injury, and improved access to advanced cardiovascular support, all of which have decreased mortality and allowed for better outcomes. Mortality after cardiac arrest is often the direct result of active withdrawal of life‐sustaining therapy based on the perception that neurological recovery is not possible. This reality highlights the importance of providing accurate estimates of neurological prognosis to decision makers when discussing goals of care. The current standard of care for assessing neurological status in patients with hypoxic‐ischemic encephalopathy emphasizes a multimodal approach that includes five elements: (1) neurological examination off sedation, (2) continuous electroencephalography, (3) serum neuron‐specific enolase levels, (4) magnetic resonance brain imaging, and (5) somatosensory‐evoked potential testing. Sophisticated decision support systems that can integrate these clinical, imaging, and biomarker and neurophysiologic data and translate it into meaningful projections of neurological outcome are urgently needed. [ABSTRACT FROM AUTHOR]

Background: We sought to examine temporal trends in management (ie, use of extracorporeal membrane oxygenation [ECMO], therapeutic hypothermia [TH], coronary angiogram, and percutaneous coronary intervention [PCI]) and in-hospital mortality in adults hospitalized with cardiac arrest. Methods: Utilizing the Nationwide Inpatient Sample, medical history, clinical management, and in-hospital mortality were assessed in 942 495 hospitalizations in adults with cardiac arrest (identified through International Classification of Diseases-9 codes) from 2006 to 2012. Results: From 2006 to 2012, there was an overall rise in the use of coronary angiogram (12.8%, 13.0%, 14.7%, 15.0%, 14.3%, 14.7%, and 15.8%), PCI (7.5%, 7.1%, 8.4%, 8.1%, 8.1%, 8.4%, and 8.9%), TH (0.2%, 0.3%, 0.6%, 1.2%, 1.9%, 2.8%, and 3.0%), and ECMO (0.1%, 0.1%, 0.1%, 0.2%, 0.2%, 0.3%, and 0.4%; P < .001 for all). In-hospital mortality significantly decreased over the 7-year study period (65.5%, 63.4%, 59.3%, 57.9%, 57.0%, 56.0%, and 56.3% from 2006 to 2012). In multivariable analysis, a 31% decrease in mortality was accompanied by a concomitant 24% and 27% increase in coronary angiogram and PCI, respectively, during the study period. Therapeutic hypothermia and ECMO were associated with an approximate 11-fold and 7-fold increase, respectively, from 2006 to 2012. The strongest predictors of use of ECMO, TH, coronary angiogram, and PCI were younger age and the presence of coronary artery disease. Conclusion: During 2006 to 2012, a decline in mortality was accompanied by a steady rise in the use of ECMO, TH, coronary angiogram, and PCI in adults hospitalized with cardiac arrest. Patients of younger age and with coronary artery disease were more likely to receive these advanced therapies. [ABSTRACT FROM AUTHOR]

Early, accurate outcome prediction after out-of-hospital cardiac arrest (OHCA) is critical for clinical decision-making and resource allocation. We sought to validate the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) score in a United States cohort and compare its prognostic performance to the Pittsburgh Cardiac Arrest Category (PCAC) and Full Outline of UnResponsiveness (FOUR) scores. This is a single-center, retrospective study of OHCA patients admitted between January 2014-August 2022. Area under the receiver operating curve (AUC) was computed for each score for predicting poor neurologic outcome at discharge and in-hospital mortality. We compared the scores' predictive abilities via Delong's test. Of 505 OHCA patients with all scores available, the medians [IQR] for rCAST, PCAC, and FOUR scores were 9.5 [6.0, 11.5], 4 [3, 4], and 2 [0, 5], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting poor neurologic outcome were 0.815 [0.763–0.867], 0.753 [0.697–0.809], and 0.841 [0.796–0.886], respectively. The AUC [95% confidence interval] of the rCAST, PCAC, and FOUR scores for predicting mortality were 0.799 [0.751–0.847], 0.723 [0.673–0.773], and 0.813 [0.770–0.855], respectively. The rCAST score was superior to the PCAC score for predicting mortality (p = 0.017). The FOUR score was superior to the PCAC score for predicting poor neurological outcome (p < 0.001) and mortality (p < 0.001). The rCAST score can reliably predict poor outcome in a United States cohort of OHCA patients regardless of TTM status and outperforms the PCAC score. [ABSTRACT FROM AUTHOR]

Introduction: Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown.Methods: Utilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables.Results: In our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26-0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91-0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07-1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05-1.25 per 10min), more likely to be female (OR: 1.41; 95% CI: 1.01-1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42-0.98).Conclusion: Patients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research. [ABSTRACT FROM AUTHOR]

Despite recent advances in perinatal care, neonatal hypoxic-ischemic encephalopathy remains one of the most common causes of neonatal morbidity and mortality. The trends for prevalence and mortality of neonatal hypoxic-ischemic encephalopathy have not been examined in the era of therapeutic hypothermia in the United States. This study aimed to determine (1) the overall and gestational age–specific (35–36, ≥37, and >42 weeks) trends of hypoxic-ischemic encephalopathy prevalence and use of therapeutic hypothermia, (2) the trends of mortality in association with hypoxic-ischemic encephalopathy, (3) the confounding variables associated with hypoxic-ischemic encephalopathy, and (4) the clinical outcomes of neonates with hypoxic-ischemic encephalopathy. This study used National Inpatient Sample datasets from 2010 to 2018. Moreover, the study included infants with a gestational age of ≥35 weeks with a documented hypoxic-ischemic encephalopathy diagnosis (mild, moderate, severe, or unspecified). We calculated trends in hypoxic-ischemic encephalopathy prevalence and the use of therapeutic hypothermia using chi-squared testing. Furthermore, this study used logistic regression models to control for confounders. A total of 32,180,617 infants were included, of which 31,249,100 were term (gestational age of ≥37 weeks) and 931,517 were late preterm (gestational age of 35–36 weeks). Hypoxic-ischemic encephalopathy prevalence slightly increased from 0.093% in 2010–2012 to 0.097% in 2016–2018 (P =.01) in term infants and did not significantly change in late preterm infants (P =.20). There were 6235 term infants (20.8%) and 449 late preterm infants (21.1%) with hypoxic-ischemic encephalopathy who were managed with therapeutic hypothermia. The use of therapeutic hypothermia in both term and late preterm infants has increased over the years (P <.01). The mortality rate with hypoxic-ischemic encephalopathy decreased over time from 11.5% to 12.3% between 2010 to 2012, and from 8.3% to 10.6% betweenn 2016 to 2018 (P <.01). The factors with the strongest association with hypoxic-ischemic encephalopathy were placental infarction or insufficiency (odds ratio, 144; 95% confidence interval, 134–157), placental abruption (odds ratio, 101; 95% confidence interval, 91–112), cord prolapse (odds ratio, 74; 95% confidence interval, 65–84), and maternal anemia (odds ratio, 26; 95% confidence interval, 20–37). Hypoxic-ischemic encephalopathy prevalence in neonates essentially remained the same at 1 per 1000 live births. The use of therapeutic hypothermia increased, and the mortality rate decreased in infants with hypoxic-ischemic encephalopathy. The identification of hypoxic-ischemic encephalopathy–associated factors should promote increased vigilance to optimize newborn outcomes. [ABSTRACT FROM AUTHOR]

Objective: Despite growing adoption, the impact of prehospital initiation of therapeutic hypothermia on outcomes of cardiac arrest patients is unknown. The objective of this study was to determine if prehospital administration of cold intravenous fluids improved the time-to-target temperature.Methods: All patients enrolled in an institutional post– cardiac arrest treatment pathway were prospectively registered into a quality assurance database. Patients undergoing cooling induction on hospital arrival were compared to those receiving a new treatment protocol initiated during the study period involving prehospital cooling with 4°C (39.2°F) normal saline. The primary outcome was the time-to-target temperature. Secondary outcomes included emergency medicine system transport time metrics, mortality, and neurologic status at discharge and 1 year.Results: One hundred thirty-two patients were enrolled during the study period. The initial rhythm was ventricular fibrillation/tachycardia in 63% and asystole/pulseless electrical activity in 36%. Eighty patients received prehospital cooling and 52 patients did not and comprised the historical control group. Time-to-target temperatures were not significantly different between prehospital and hospital cooled groups (256 v. 271 minutes, respectively, p=0.64), nor was there any improvement in hospital survival (54% v. 50%, p=0.67), good neurologic outcome (49% v. 44%, p=0.61), or 1- year survival (49% v. 42%, p=0.46) between the two groups. Transport times were longer in the prehospital cooled group.Conclusions: Out-of-hospital cardiac arrest patients treated with prehospital cooling before arrival at our urban hospital did not have faster time-to-target temperature or improvement in outcomes compared to patients cooled immediately on emergency department arrival. Further research is needed to determine if any benefits exist from prehospital cooling prior to its widespread adoption. [ABSTRACT FROM PUBLISHER]

Targeted temperature management (TTM) is a complex and sophisticated intensive-care procedure that is included in the American Heart Association guidelines for treating patients who remain unconscious after resuscitation from cardiac arrest. TTM has been demonstrated to reduce brain injury associated with reperfusion after resuscitation and to improve the neurological prognosis in patients with cardiac arrest. The TTM process may be divided into four phases: induction, maintenance, rewarming, and normothermia. The critical element in TTM is the quick lowering and slow raising of body temperature, which should be fine-tuned to maintain temperature stability and minimize variation. Caregivers should monitor the physiological changes caused by core body temperature change closely and manage possible complications such as shivering, hypo- and hyper-glycemia, electrolyte imbalance, skin injury, arrhythmia, and infection. Based on contemporary evidence and clinical experience, this article provides critical care nurses a summary and key points of each stage of TTM when used to take care of resuscitated patients after cardiac arrest. We hope this work may help improve patient safety and quality of care during the TTM procedure.

Abstract: Introduction: Recent studies have suggested that serum lactate may serve as a marker to predict mortality after resuscitation from cardiac arrest (CA). The relationship between serum lactate and CA outcomes requires further characterization, especially among patients treated with therapeutic hypothermia (TH) and aggressive post-arrest care. Methods: A retrospective analysis of patients resuscitated from non-traumatic CA at three urban U.S. hospitals was performed using an established internet-based post-arrest registry. Adult (≥18 years) patients resuscitated from CA and receiving TH treatment were included. Logistic regression analysis was used to adjust for potential confounders to survival outcomes. Survival to discharge served as the primary endpoint. Results: A total of 199 post-CA patients treated with TH between 5/2005 and 11/2011 were included in this analysis. The mean age was 56.9±16.5 years, 85/199 (42.7%) patients were female, and survival to discharge was attained in 84/199 (42.2%). While lower initial post-CA serum lactate levels were not associated with increased survival to discharge, subsequent lactate measurements were significantly associated with outcomes (24-h serum lactate levels in survivors vs. non-survivors, 2.7±0.5 vs. 4.2±0.4mmol/L, p <0.01). Multivariable logistic regression confirmed this relationship with survival to discharge (p <0.01). Conclusion: Lower serum lactate levels at 12h and 24h, but not initially following cardiac arrest, are associated with survival to hospital discharge after resuscitation from CA and TH treatment. Prospective investigation of serum lactate as a potential prognostic tool in CA is needed. [Copyright &y& Elsevier]

Abstract: Objective: The American Heart Association recently recommended regional cardiac resuscitation centers (CRCs) for post-resuscitation care following out-of-hospital cardiac arrest (OHCA). Our objective was to describe initial experience with CRC implementation. Methods: Prospective observational study of consecutive post-resuscitation patients transferred from community Emergency Departments (EDs) to a CRC over 9 months. Transfer criteria were: OHCA, return of spontaneous circulation (ROSC), and comatose after ROSC. Incoming patients were received and stabilized in the ED of the CRC where advanced therapeutic hypothermia (TH) modalities were applied. Standardized post-resuscitation care included: ED evaluation for cardiac catheterization, TH (33–34°C) for 24h, 24h/day critical care physician support, and evidence-based neurological prognostication. Prospective data collection utilized the Utstein template. The primary outcome was survival to hospital discharge with good neurological function [Cerebral Performance Category 1 or 2]. Results: Twenty-seven patients transferred from 11 different hospitals were included. The majority (21/27 [78%]) had arrest characteristics suggesting poor prognosis for survival (i.e. asystole/pulseless electrical activity initial rhythm, absence of bystander cardiopulmonary resuscitation, or an unwitnessed cardiac arrest). The median (IQR) time from transfer initiation to reaching TH target temperature was 7(5–13)h. Ten (37%) patients survived to hospital discharge, and of these 9/10 (90% of survivors, 33% of all patients) had good neurological function. Conclusions: Despite a high proportion of patients with cardiac arrest characteristics suggesting poor prognosis for survival, we found that one-third of CRC transfers survived with good neurological function. Further research to determine if regional CRCs improve outcomes after cardiac arrest is warranted. [Copyright &y& Elsevier]

Abstract: Background: Therapeutic hypothermia (TH) has been demonstrated to improve clinical outcomes after out-of-hospital ventricular fibrillation (VF) cardiac arrest. It remains unclear if TH can be safely and effectively used in the setting of traumatic arrest. Furthermore, the use of TH methods in the pre-hospital and transport environments remain poorly established and a domain of active investigation. Objectives: To describe a case of successful TH utilization after blunt trauma with commotio cordis and pulmonary contusion, and to describe the continuation of TH during international fixed-wing aeromedical transport. Case Report: A 33-year-old active duty soldier suffered blunt chest trauma and immediate VF arrest. He was successfully resuscitated with cardiopulmonary resuscitation and defibrillation attempts. Given his ensuing comatose post-arrest state, he was therapeutically cooled and subsequently evacuated from Iraq to Germany, with cooling maintenance established in flight without the availability of training or commercial cooling equipment. The patient exhibited an eventual excellent neurologic recovery. To utilize TH for this patient, military physicians with limited local resources employed a telemedical approach to obtain a hypothermia protocol to develop a successful treatment plan. Conclusions: The patient''s successful resuscitation suggests that care should not be withheld for blunt trauma patients without vital signs in the field if VF is present, until the differential diagnosis of commotio cordis has been considered. [Copyright &y& Elsevier]

Therapeutic hypothermia allows us to improve both survival and neurological recovery in patients with different causes of neuronal aggression. This article is based on demographic studies conducted both in the U.S. and Europe, and aims to present the pathophysiological mechanisms of these therapeutic methods and their indications, focusing on patients who suffered cardiac arrest. There are also presented criteria for including and excluding patients in the studies, methods of inducing hypothermia, and treatment protocols. Variables related to the timing of the start method of cooling, process cooling, rate, depth, duration of cooling and reheating are disputed here, which may all have an impact on mortality and morbidity. However, at this time, these variables are not well studied and are at present in several experimental and clinical studies. In addition, these variables are most likely to have different levels of importance depending on clinical indications. [ABSTRACT FROM AUTHOR]

Abstract: Neonatal encephalopathy (NE) secondary to intrapartum asphyxia remains a major cause of post-natal death and permanent neurological deficits worldwide. Supportive therapy has been the mainstay of the treatment until recent series of large clinical trials demonstrating benefit of therapeutic hypothermia (TH) in this high risk population. Now the International Liaison Committee on Resuscitation (ILCOR) recommends TH as a standard of care with the protocols used in the large clinical trials as tentative standard protocols. Our goal is to develop a nationwide consensus practice guideline not only consistent with the international standard protocols but also practical and compatible with the current medical system in Japan. In summary, TH should be offered to newborn infants born ⩾36weeks gestational age and birth weight ⩾1800g exhibiting clinical signs of moderate to severe NE as well as evidence of hypoxia–ischemia, i.e. 10min Apgar score ⩽5, a need for resuscitation at 10min, blood pH<7.00, or base deficit ⩾16mmol/L. TH should be conducted in the NICUs capable of multidisciplinary care and under the standard protocols, i.e. utilization of cooling device, target (rectal or esophageal) temperatures at 33.5±0.5 and 34.5±0.5°C for whole body and selective head cooling respectively, duration of TH for 72h, gradual rewarming not exceeding the rate of 0.5°C/h. Long term follow-up with multidisciplinary approach including standardized psychological assessment is warranted. [Copyright &y& Elsevier]

Spinal cord injury is a devastating condition that affects approximately 12,000 patients each year in the United States. Major causes for spinal cord injury include motor vehicle accidents, sports-related injuries, and direct trauma. Moderate hypothermia has gained attention as a potential therapy due to recent experimental and clinical studies and the use of modest systemic hypothermia (MSH) in high profile case of spinal cord injury in a National Football League (NFL) player. In experimental models of spinal cord injury, moderate hypothermia has been shown to improve functional recovery and reduce overall structural damage. In a recent Phase I clinical trial, systemic hypothermia has been shown to be safe and provide some encouraging results in terms of functional recovery. This review will summarize recent preclinical data, as well as clinical findings that support the continued investigations for the use of hypothermia in severe cervical spinal cord injury. [ABSTRACT FROM AUTHOR]

Purpose. The use of therapeutic hypothermia (TH) and its application in out of- hospital cardiac arrest patients are reviewed. Summary. Each year in the United States, an estimated 250,000-300,000 out-of-hospital cardiac arrests occur. Despite advances in prehospital care, the survival rate from TH is only 6-12%. In addition, survivors often have devastating consequences ranging from mild memory impairment to permanent brain damage. It is presumed that early induction of hypothermia produces an optimal effect, though benefits can still be achieved with late induction. Several methods have been devised to induce hypothermia, yet the optimal methods of cooling have not currently been determined. Major adverse effects of cooling include hemodynamic changes, cardiovascular complications, hyperglycemia, coagulopathy, increased rates of infection, fluid and electrolyte disorders, and shivering. The majority of these adverse effects can be prevented or minimized in the intensive care setting. In 2002, the use of TH-cooling the core body temperature to 32-34 °C-was supported by two landmark human studies, whose results led to the endorsement of TH by the American Heart Association and its increased use. The studies demonstrated that hypothermia results in favorable neurologic outcomes in patients suffering from out-of-hospital cardiac arrest due to ventricular fibrillation (VF), without increasing complications. Conclusion. TH is an effective strategy for improving neurologic outcomes of patients after out-of-hospital cardiac arrest due to VF. Further studies are needed to confirm the optimal time and methods for cooling to maximize the chance of complete neurologic recovery after cardiac arrest. [ABSTRACT FROM AUTHOR]

Dexmedetomidine is a centrally acting α2-adrenergic agonist which is currently Food and Drug Administration- approved for the short-term (less than 24 hours) sedation of adults during mechanical ventilation. Given its beneficial physiologic effects and limited adverse effect profile, there is growing interest regarding its potential applications in the Pediatric intensive care unit patient including sedation during mechanical ventilation, procedural sedation, the treatment of withdrawal, and prevention of emergence agitation. Although generally safe and effective, occasional hemodynamic effects including bradycardia and hypotension have been reported. Clinical experience has demonstrated that bradycardia may be more common when dexmedetomidine is administered with other medications that have negative chronotropic effects. We report 2 pediatric patients with traumatic brain injury who had good long-term neurologic outcomes, but developed clinically significant bradycardia when therapeutic hypothermia was added to a sedation regimen that included dexmedetomidine and remifentanil. The role of dexmedetomidine as a neuroprotective agent is explored as well as a review presented of previous reports of bradycardia related to dexmedetomidine. [ABSTRACT FROM AUTHOR]

OBJECTIVE. A selective head-cooling device for the treatment of moderate to severe hypoxic-ischemic encephalopathy has been approved by the Food and Drug Administration for use in the United States. To reflect the complexity of health care delivery at the systems level, we used the industrial modeling technique of discrete event simulation to analyze the impact of various deployment strategies for selective head cooling and its partner technology, amplitude-integrated electroencephalography. METHODS. We modeled the course through the perinatal system of all births in Massachusetts over a 1-year period. Cohort and care characteristics were drawn from existing databases. Results of a recently published trial were used to estimate the effects of selective head cooling. One thousand cohort replications were conducted to assess uncertainty. Several policy alternatives were examined, including no use of selective head cooling and scenarios that altered the number and placement of selective head-cooling and amplitude-integrated electroencephalography units throughout the state. Patient-level outcome and cost data were assessed. RESULTS. For all scenarios tested, the use of amplitude-integrated electroencephalography/ selective head cooling resulted in better outcomes at lower cost. However, substantial differences in transfer rates, failure-to-cool rates, and total costs were seen across scenarios. Optimal decision-making regarding the number and placement of devices led to a 16% improvement in cost savings and a 10-fold decrease in failure-to-cool rates, compared with other deployment scenarios. These results were insensitive to significant changes in model inputs. CONCLUSIONS. On the basis of currently available data, the package of amplitude-integrated electroencephalography and selective head cooling seems to be an economically desirable intervention. Quantifiable techniques to assess system-wide technology performance provide a powerful approach to informing decisions regarding the structure and function of health care systems. [ABSTRACT FROM AUTHOR]

The article focuses on the effort of clinical researchers in the U.S. to understand how mild hypothermia therapy improves survival of people experiencing cardiac arrest and other types of trauma. With the growing use of hypothermia therapy and the number of high profile failures and some safety concerns associated with therapy, several researchers are conducting studies on the technique using animal models. Among the remarkable studies on hypothermia's beneficial effect was led by emergency medicine doctor Fritz Sterz, and a 2005 study that applied mild hypothermia therapy in babies deprived of oxygen before birth. Meanwhile, the study on hypothermia's application in head injury led by neurosurgeon Guy Clifton suggests that early cooling is the key to effective hypothermia therapy.

Objectives: Therapeutic hypothermia is an effective neuroprotective intervention for infants with moderate or severe hypoxic-ischemic encephalopathy (HIE). With the introduction of new medical therapy comes a learning curve with regards to its proper implementation and understanding of eligibility guidelines. We hypothesized that variation in patient selection and lack of adherence to established protocols contributed to the utilization drift away from the original eligibility guidelines., Methods: A retrospective cohort study was conducted including infants who received therapeutic hypothermia in the neonatal intensive care unit (NICU) for HIE to determine utilization drift. We then used QI methodology to address gaps in medical documentation that may lead to the conclusion that therapeutic hypothermia was inappropriately applied., Results: We identified 54% of infants who received therapeutic hypothermia who did not meet the clinical, physiologic, and neurologic examination criteria for this intervention based on provider admission and discharge documentation within the electronic medical record (EMR). Review of the charts identified incomplete documentation in 71% of cases and led to the following interventions: 1) implementation of EMR smartphrases; 2) engagement of key stakeholders and education of faculty, residents, and neonatal nurse practitioners; and 3) performance measurement and sharing of data. We were able to improve both adherence to the therapeutic hypothermia guidelines and achieve 100% documentation of the modified Sarnat score., Conclusions: Incomplete documentation can lead to the assumption that therapeutic hypothermia was inappropriately applied when reviewing a patient's EMR. However, in actual clinical practice physicians follow the clinical guidelines but are not documenting their medical decision making completely. QI methodology addresses this gap in documentation, which will help determine the true utilization drift of therapeutic hypothermia in future studies., (© 2020 Walter de Gruyter GmbH, Berlin/Boston.)

Purpose: We describe the frequency and timing of withdrawal of life-support (WLS) in moderate or severe hypoxic-ischemic encephalopathy (HIE) and examine its associations with medical and sociodemographic factors., Procedures: We undertook a secondary data analysis of a prospective multicenter data registry of regional level IV Neonatal Intensive Care Units participating in the Children's Hospitals Neonatal Database. Infants ≥36 weeks gestational age with HIE admitted to a Children's Hospitals Neonatal Database Neonatal Intensive Care Unit between 2010 and 2016, who underwent therapeutic hypothermia were categorized as (1) infants who died following WLST and (2) survivors with severe HIE (requiring tube feedings at discharge)., Results: Death occurred in 267/1,925 (14%) infants with HIE, 87.6% following WLS. Compared to infants with WLS (n = 234), the survived severe group (n = 74) had more public insurance (73% vs 39.3%, P = 0.00001), lower household income ($37,020 vs $41,733, P = 0.006) and fewer [20.3% vs 35.0%, P = 0.0212] were from the South. Among infants with WLS, electroencephalogram was performed within 24 hours in 75% and was severely abnormal in 64% cases; corresponding rates for MRI were 43% and 17%, respectively. Private insurance was independently associated with WLS, after adjustment for HIE severity and center., Conclusions: In a multicenter cohort of infants with HIE, WLS occurred frequently and was associated with sociodemographic factors. The rationale for decision-making for WLS in HIE require further exploration., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: The study aimed to assess the impact of therapeutic hypothermia (TH) on bleeding and in-hospital mortality among patients with coagulation disorders (CD)., Background: TH affects coagulation factors and platelets putting patients at risk for bleeding and worse outcomes. Effect of TH among patients with CD remains understudied., Methods: Between 2009 and 2014, a total of 6469 cases of TH were identified using the National Inpatient Sample out of which 1036 (16.02%) had a CD. The incidence of bleeding events, blood product transfusion and in-hospital mortality was compared between patients with and without CD using one to one propensity score matching., Results: Proportion of patients with CD increased during study duration from 13.0% to 17.4% from 2009 to 2014. Propensity matching was performed to adjust for baseline differences with 799 patients in both groups depending on presence or absence of CD. Patients with CD had a higher rate of bleeding events (13% vs. 8.5%; adjusted odds ratio 1.60; 95% confidence interval 1.16-2.23; P = 0.004), and blood product transfusion (25.0% vs. 14.1%; aOR 2.03; 95% CI 1.56-2.63; p < 0.001) compared to those without CD. There was no difference in rate of intracranial bleeding or hemorrhagic strokes between those with and without CD (3.3% vs. 3.2%; p = 0.88). There was no difference in mortality between patients with CD and those without (74.5% vs. 74.8%, aOR 0.98, 95% CI 0.78-1.23; P = 0.86)., Conclusions: Use of TH with CD resulted in more bleeding events and blood product transfusion but there was no difference in hospital mortality., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Therapeutic hypothermia has demonstrated an improvement in neurological outcomes in patients who experience sudden cardiac arrest. The benefit of this therapy is documented only after its implementation in a one-time basis. We report the case of a patient who suffered two events of sudden cardiac arrest separately in a short period of time and who underwent therapeutic hypothermia after each episode with outstanding results. [ABSTRACT FROM AUTHOR]

The author reflects on the rare practice in medical communities in Canada and U.S. of using mild therapeutic hypothermia (TH) in patients of cardiac arrest to improve their survival and neurologic recovery. The author argues that the lack of sufficient guidelines is the reason why TH is seldom used as a lifesaving intervention. The author cites the qualitative study by A. Toma and colleagues on the use of TH as the right step towards the understanding of TH for the patient's benefit.

The author reflects on the retrospective cohort study on children between 24 hours and 18 years with cardiac arrest (CA) and return of circulation from in-hospital (IH) and out-of-hospital (OH) settings from 15 pediatric emergency care centers in the U.S. by Moler and colleagues. It aims to describe the variables and results of prearrest, arrest, and early post arrest at hospital discharge, to compare the characteristics of IH and OH. Details on the diferrence between IH and OH are discussed.

Background: Therapeutic hypothermia (TH) improves the outcome of comatose patients suffering an out-of-hospital sudden cardiac arrest (SCA) with shockable rhythm and return of spontaneous circulation (ROSC). Evidence supporting its use in other circumstances is weak and the adoption of TH remains limited., Objective: Describe the development and implementation of a TH program at an urban public hospital and report outcomes of out-of-hospital and in-hospital SCA and important quality measures., Methods: The protocol was developed at 464-bed urban public hospital. We assembled historical and prospective samples of patients suffering an SCA. We measured the neurologic outcome of patients at the time of hospital discharge who underwent TH after SCA. We compared outcomes and important quality measures (duration of arrest, time to cooling, and time to target temperature) to existing literature. We determined reasons for not using TH in patients with in-hospital SCA., Results: We described the development of our TH program and the challenges we faced implementing it. Of 45 patients treated with TH after SCA, 23 (51%) survived to discharge, 14 (31%) with good neurologic outcomes. In comparison to historical controls, TH did not improve outcome of in-hospital SCA. SCA from a shockable rhythm was associated with the best outcome. The time from return of spontaneous circulation to initiation of TH was consistently within 8 h., Conclusions: Despite logistical and financial constraints, we were able to rapidly implement a TH program with quality and outcomes similar to published data. TH did not improve outcomes for patients with an in-hospital SCA., (Published by Elsevier Inc.)

Aims: Neurological outcome prognosis remains challenging in patients undergoing therapeutic hypothermia (TH) after cardiac resuscitation. Technological advances allow for a novel wrist-worn device to continuously record electrodermal activity (EDA), a measure of pure sympathetic activity., Methods: A prospective cohort study was performed to determine the yield of continuous EDA in patients treated with TH for coma after cardiac arrest during hypothermia and normothermia. Association between EDA parameters (event-related and nonspecific electrodermal responses (ER-EDR, NS-EDR)) and outcome measures (cerebral performance category [CPC]) (Full Outline in UnResponsivenss (FOUR) score) were assessed., Results: Eighteen patients were enrolled. Total number of EDR (66.4 vs 12.0/24h, p = 0.02), ER-EDR (39.5 vs 11.2/24h, p = 0.009), median amplitude change of all EDR (0.08 vs 0.03 μSI, p = 0.03) and ER-EDR (0.14 vs 0.05 μSI, p = 0.025) were higher in patients with favorable (CPC 1-2) versus poor outcome (CPC 3-5) during hypothermia. Greater differences in EDA parameters were observed during hypothermia than normothermia. The FOUR score was correlated to the number of all EDR and median amplitudes., Conclusions: Continuous EDA potentially opens a new avenue for autonomic function monitoring in neurocritically ill patients. It is feasible in the ICU setting, even during hypothermic states. As a measure of a complete neurophysiological circuit, it may be a novel neurophysiologic biomarker of outcome after cardiac resuscitation., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Induction of mild therapeutic hypothermia (TH; temperature 32-34°C) has become standard of care in many hospitals for comatose survivors of cardiac arrest. Pyrexia, or fever, is known to be detrimental in patients with neurologic injuries such as stroke or trauma. The incidence of pyrexia in the postrewarming phase of TH is unknown. We attempted to determine the incidence of fever after TH and hypothesized that those patients who were febrile after rewarming would have worse clinical outcomes than those who maintained normothermia in the postrewarming period., Methods: Retrospective data analysis of survivors of out-of-hospital cardiac arrest (OHCA) over a period of 29 months (December 2007 to April 2010)., Inclusion Criteria: OHCA, age >18, return of spontaneous circulation, and treatment with TH., Exclusion Criteria: traumatic arrest and pregnancy. Data collected included age, sex, neurologic outcome, mortality, and whether the patient developed fever (temperature > 100.4°F, 38°C) within 24 hours after being fully rewarmed to a normal core body temperature after TH. We used simple descriptive statistics and Fisher exact test to report our findings., Results: A total of 149 patients were identified; of these, 82 (55%) underwent TH. The mean age of the TH cohort was 66 years, and 28 (31%) were female. In all, 54 patients survived for >24 hours after rewarming and were included in the analysis. Among the analyzed cohort, 28 (52%) of 54 developed fever within 24 hours after being rewarmed. Outcome measures included in-hospital mortality as well as neurologic outcome as defined by a dichotomized Cerebral Performance Category (CPC) score. When comparing neurologic outcomes between the groups, 16 (57%) of 28 in the postrewarming fever group had a poor outcome (CPC score 3-5), while 15 (58%) of 26 in the no-fever group had a favorable outcome (P = .62). In the fever group, 15 (52%) of 28 died, while in the no-fever group, 14 (54%) of 26 died (P = .62)., Conclusion: Among a cohort of patients who underwent mild TH after OHCA, more than half of these patients developed pyrexia in the first 24 hours after rewarming. Although there were no significant differences in outcomes between febrile and nonfebrile patients identified in this study, these findings should be further evaluated in a larger cohort. Future investigations may be needed to determine whether postrewarming temperature management will improve the outcomes in this population., (© The Author(s) 2013.)

Background: Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH., Methods: This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC., Results: 105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0-32.3)min and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (≤10min, 11-20min, 21-30min, >30min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20min, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm., Conclusions: Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime >20min., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)