Intra-arrest therapeutische hypothermie Fabienne Roossien, AIOS SEH Regionaal refereren 18-07-2013
Feb 25, 2016
Intra-arrest therapeutische hypothermie
Fabienne Roossien, AIOS SEHRegionaal refereren 18-07-2013
Inhoud• Achtergrond• Search• Studies• Conclusie • Discussie• THM
Achtergrond• Dierstudies:– Intra-arrest TH 1-4 : • betere kans op ROSC & survival• betere neurologische uitkomst
• Veilig, uitvoerbaar 5-7
• Effect mensen?
Search
Search• Medline/CINAHL:– Intra-arr*/ intra arr* AND hypothermia– 27 hits => 2 relevant
• Embase– Therapeutic/Induced hypothermia AND intra-
arrest– 63 hits=> 6 relevant, 3 cf. pubmed, 3 abstracts
(2 AHA congres 2011; 1 Critical Care congres 2011)
Artikelen• Castren et al.
Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC intranasal cooling effectiveness). Circulation 2010; 122: 729-736
• Garret et al.The association between intra-arrest therapeutic hypothermia and return of spontaneous circulation among individuals experiencing out of hospital cardiac arrestResuscitation 82 (2011) 21–25
Abstracts• J. Freese
Intra-arrest induction of therapeutic hypothermia via large-volume ice-cold saline infusion improves immediate outcomes for out-of-hospital cardiac arrest
Intra-arrest induction of therapeutic hypothermia via large-volume, ice-cold saline infusion results in improved outcomes among out-of-hospital cardiac arrests of cardiac etiologyCirculation 2011 124: A97& A2
• Castren et al.Earlier intra-arrest transnasal cooling may be beneficialCritical care 2011, 15(suppl):P303
Auteur
Patient groep
Studie type
Inter-ventie
Vergelijking
Outcomes Resultaten Study Weaknessess
Level
Castren et al.2010
194ptn>18jr met OHCA
93 IATH101 control
Prospectief RCT
IATH d.m.v. trans-nasal cooling(rhino chill)
Geen IATH Efficacy:coolingrates
ROSC rates
Survival to discharge
Neurologische outcome bij ontslag
Vergelijkbare groepen
ROSC:IATH 37,6% vs 42,6% (p 0,48)
Survival:IATH 43,8% vs 31% (p 0,26)
Neuro:IATH 34,4% vs 21,4% (p 0,21)
CPR<10min:ROSC IATH 56,5% vs 29,4% (p 0,04)
Neuro: IATH 43,5% vs 17,6% (p 0,03)
Verschil tijd tot intubatie (niet verklaard)
Manier van koelen
2
Auteur
Patient groep
Studie type
Inter-ventie
Vergelijking
Outcomes Resultaten Study Weaknessess
Level
Garret et al.
2011
542 ptn>18jrmet OHCA
208 IATH334 niet
Retrospectief
History-control
Intra-arrest TH: 2L 4gr NaCl 0,9%Max. 2LIntra-arrest
Geen intra-arrest TH
Time to ROSC
Survival admission
Survival discharge
Vergelijkbare groepen
36,5% ROSC IATH-groep vs. 26,9%(p 0,018)
OR 1,83
Niet significant:28,4% survival bij opname vs 23,4%
12,5% survival tot ontslag vs 12%
>700cc koud zout significant vaker ROSC pre-hospital
Retrospectief
Vulling met koude infusie versus geen vulling
Verschillend moment in tijd
4
Auteur
Patient groep
Studie type
Inter-ventie
Vergelij-king
Outcomes Resultaten Study Weaknessess
Level
Freese et al.
2011
8040OHCA(cardiale oorzaak)
4459 control3581 TH
Retro-spectief
Historycontrol
Intra-arrest TH met koud NaCl 0,9%
Geen intra-arrest TH
Directe overleving
Vergelijkbare groepen
6,5% vs. 7,8% witnessed arrests (p0,03)
31,1% vs. 26,8% ROSC(p<0,0001)
23,6% vs. 19,9%blijvend ROSC(p<0,0001)
Abstract
Retrospectief
Groepen verschillend moment behandeld
ntb
Freese et al.
10309 OHCA (niet trauma)
5582 control4727 TH
“ “ “ “ 8,3% vs. 9,5% witnessed arrest(p0,026)
31,7% vs. 29%ROSC(p<0,003)
24,1% vs. 21,9%blijvend ROSC(p<0,0014)
“ ntb
Auteur
Patient groep
Studie type
Inter-ventie
Vergelijking
Outcomes Resultaten Study Weaknessess
Level
Castren
2011
41 ptn met OHCA
19 IATH22 control
ProspectiefRCT
IATH d.m.v. trans-nasal cooling(Rhino chill)
Geen IATH ROSC rate ROSCIATH 42% vs 36% control
Site 1: cooling @ 11 min
ROSC50% IATH vs 11% control (CPR IATH 5min vs 7min control)
Site 2: cooling@20min
ROSC39% IATH vs 54% control(CPR IATH 7min vs 9min control)
Abstract
Verschil in start CPR en cooling
ntb
Conclusie studies
• IATH middels infusie/transnasaal• Veilig en haalbaar• Trend naar meer ROSC, • Wschl. ook meer survival en betere neurologie • M.n. bij snelle start CPR en snelle start IATH
Discussie• Beperkte humane studies• Abstracts veelbelovend, grote
aantallen, nog niet uitgewerkt• Meer ROSC bij IATH • Relatie ROSC-survival-neurologie nog
niet bewezen
• Meer RCT’s nodig met primaire doel survival/ neurologie
THM• O.b.v. eerder onderzoek: – geen adverse events, IATH haalbaar,
neiging naar meer ROSC
• Positief effect• Echter: veilig en haalbaar, dus…
• Keep it cool & fast!
Vragen?
Referenties1. Nozari et al. Critical time window for intra-arrest cooling with cold-saline flush in a dog model of CPR
Circulation 2006; 113; 2690-62. Zhao et al. Intra-arrest cooling with delayed reperfusion yields higher survival than earier normothermic
resuscitatoion in a mouse-model. Resuscitation 2008; 77:242-93. Abella et al. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation 2004;
109:2786-914. Menegazzi et al Effects of pre-arrest and intra-arrest hypothermia on ventricular defirillation and resuscitation
Resuscitation 2009; 80:126-325. Bernard et al. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of
out-of-hospital cardiac arrest: a preliminary report. Resuscitation 2003, 56:9-13.6. Kim F et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-ofhospital cardiac
arrest patients with a rapid infusion of 4 degrees C normal saline. Circulation 2007, 115:3064-3070.7. Virkkunen I et al. Induction of therapeutic hypothermia after cardiac arrest in prehospital patients using ice-
cold Ringer's solution: a pilot study. Resuscitation 2004, 62:299-302.8. Castren et al. Intra-arrest transnasalevaporative cooling: a randomized, prehospital, multicenter study
(PRINCE: Pre-ROSC intranasal cooling effectiveness). Circulation 2010; 122: 729-7369. Garret et al. The association between intra-arrest therapeutic hypothermia and return of spontaneous
circulation among individuals experiencing out of hospital cardiac arrest Resuscitation 82 (2011) 21–2510. Scolletta et al. Intra-arrest hypothermia during cardiac arrest: a systematic review. Critical Care 2012, 16:R4111. Freese Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume, Ice-Cold Saline Infusion Results in
Improved Outcomes Among Out-of-Hospital Cardiac Arrests of Cardiac Etiology 12. Freese Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume Ice-Cold Saline Infusion Improves
Immediate Outcomes for Out-of-Hospital Cardiac Arrest13. Castren et al . Earlier intra-arrest transnasal cooling may be beneficial
Critical care 2011, 15(suppl):P303