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Does cooling of ROSC patients in the pre-hospital setting have a better recovery than patients who don't receive pre-hospital cooling
Research Literature Review
PARA 257- EMS Research Methods
Nasser C. Deinla
Submitted to: Jason Buick
April 13, 2016
Neurological deficits secondary to a brain injury is one of the most leading causes of complications or even death associated with post cardiac arrest patients (Cronberg&Lilja, 2015). When the heart stops pumping, It stop the circulation of blood to the brain. As a result, the brain enters a period of hypoperfusion in which the brain suffers from hypoxia. Experimental evidence dictates that the brain experiences irreversible injury within minutes of acute ischemia (Schwartz, B. G. et al., 2012). A study has shown that almost half of cardiac arrest survivors report having cognitive problems a year after the arrest (Lilja et al., 2015). The brain is the organ that most influences the survival of a patient (Anderson, 2009). Another complication that is associated with hypoperfusion and neurological deficits is reperfusion injury. This occurs when cardiac function is restored, the deoxygenated blood that was stagnant in the system is now being pumped throughout the body, to brain and other organs. Reperfusion injury also initiates the production and release of chemical reactions that can lead to disruption of cerebral autoregulation, mitochondrial damage, and eventually programmed cell death or apoptosis (Bahrt, 2009). By initiating therapeutic hypothermia in patients who have achieved a return of spontaneous circulation (ROSC), it can slow progression of the injury, promote neurological recovery and improve their quality of life post-cardiac arrest.
Research states that patients who were cooled within 2 h after ROSC had good outcome and discharge with favourable neurological outcome. This study shows comatose patients with OHCA were randomized to normothermia or cooled to 33 degrees C within 2 hour after ROSC and were kept at that temperature for 12 hours (Bernard et al., 2010). The results revealed that of 43 patients in the hypothermic group, 49% had good outcome compared with 26% of 34 patients assigned to the normothermic group. In another study, authors found that therapeutic hypothermia (TH) of patients who had ventricular fibrillation as initial rhythm during cardiac arrest has a good outcome compared to patients who showed asystole or pulseless electrical activity. 55.8% of 43 hypothermia patients with ventricular fibrillation had good recovery compared to only 25.6% of 43 patients with other rhythm and was normothermic temperature. TH is an intervention that can easily be implemented, and if used correctly, it can have a long lasting effect to patient’s quality of life post-cardiac arrest. A recent guideline from the 2015 American Heart Association (AHA) for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommends using mild TH. They have advised achieving a core temperature of 32-34 degrees Celsius for OHCA in adults who have achieved a ROSC within a 24 h window (Donnino et al., 2015). In addition an Emergency response systems that instituted TH in their clinical algorithms have shown improved survival rates and improved neurological recovery as well (Mooney M.R et al., 2011). This is also consistent with the Ontario Paramedic Clinical Guide in the Advance Life Support (ALS) under the Return of Spontaneous Circulation directive. Therapeutic Hypothermia is an intervention with certain condition that needs to be met (ALS, 2011). These criteria are as follows. Greater or equal to 18 years of age in males and greater or equal to 50 years of age in females, must have altered level of consciousness and a systolic blood pressure with a value of greater or equal to 90mmHg (spontaneous or following bolus). Another study shows that early initiation of TH in the pre-hospital setting couple with in-hospital TH can predict a favourable neurological outcome at hospital discharge and potentially improve prognosis of the patient condition (Skulec, 2010). This is achieved by an administration of intravenous of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital. The hallmark sign that is measure is the tympanic temperature (TT). It showed a decreased in temperature on arrival to the hospital, which is less than 34 degrees Celsius. The neurological outcome was also assessed by the method of cerebral performance category (CPC). A score value of 1 or equal to 1 has a good neurological function whereas a score value of 3 or equal to 3 elicits poor neurological function (Skulec, 2010). Pre-hospital induction of TH by the rapid intravenous administration of crystalloid (RIVA) method has been shown to be efficient and beneficial. With the dosage of 15-20ml/kg of saline is associated with favourable impact on the circulatory stability early after the ROSC and when quickly followed by in-hospital TH, this can potentially improve the prognosis of the patients. Early administration of Intravenous therapy coupled with surface cooling in the hospital setting also increases the survival rate of the patient (Skulec, 2010).
Though TH seems beneficial, other studies states that it can have detrimental effects to the patients as well. This includes impaired physiological activities to blood circulation, respiration, coagulation and hepatic and renal activities (Soleimanpour & Rahmani, 2013). TH is achieved when a core body temperature is aimed at 30 to 34 degrees Celsius and is deemed helpful for OHCA. However, as temperature decreases even further to 28-30 degrees Celsius, it can cause electrolyte imbalances that make the heart prone to cardiac arrhythmias such as atrial fibrillation that can be followed by severe arrhythmia including ventricular tachycardia and ventricular fibrillation (Darwazeh et. Al., 2013).
A randomized controlled trial (RCT) conducted by Kim et al. had a hypothesis that initiation of TH immediately after a ROSC will have a better survival rate and a good neurological outcome. This RCT showed a decrease in the ROSC patient’s core body temperature. However, it was associated with higher incidence of re-arrest and other complication such as pulmonary edema. The study focused on 583 patients from a prehospital setting and induced mild TH with large boluses and cooled normal saline right after a ROSC. Kim et al had a cohort size of 1359 patients. This group was divided in two. One group was focused on 583 patients who presented with ventricular fibrillation (VF) and 776 patients who did not. These two groups were further divided. The VF group was divided into intervention group and control group. 292 was cooled (intervention) and 291 in the control group. In the non-VF, 396 is cooled and 380 in the control group. The cooled group was given 2 – 4L of cooled Normal saline (NS) to reach the targeted core body temperature of 34 degrees Celsius. The results of survival rates at discharge are as follows. VF cooled group showed 62.7% and controlled group with 64.3%. The non-VF cooled group showed 19.2% and controlled group with 16.3%. Neurological status of full recovery & mild impairment is as follows. VF cooled group at 57.5% and control group at 61.9%. The non-VF cooled group at 14.4% and control group at 13.4% (Kim et al., 2015). The survival rate for the VF control group is 1.6% higher than VF of cooled group. While the non-VF cooled group is 2.9% higher than the control group. In addition, the neurological status recovery percentage for control group is 4.4% higher than the cooled group and the non-VF cooled group is 1% higher than the control group. Drawing conclusion from this study, it is evident that there are conflicting results when reporting survival rates and neurological outcomes with TH. TH had no significant impact on either the VF or non-VF group on neurological status during hospital discharge.
With evidence from various studies both showing pros and cons about the initiation of TH in the pre-hospital setting, is it very hard to draw a conclusion as to what is more beneficial for ROSC patients. Though there are studies that showed TH is highly recommended for ROSC patients as per American Health Association (AHA) (Donnino et al.,2015), there are far more recent evidences that shows TH being detrimental to patient recovery and neurological function. As a result, this literature review is unable able to provide a clear answer regarding the effectiveness and the benefits of TH in the pre-hospital environment. Interestingly enough, an author Villablanca et al (2016) has stated that TH in OHCA showed minimal to no increase in the survival or neurological recovery of patients. With this information in mind, there is no question that continuation of research regarding TH has yet to be completed; it needs more proven facts and more recent studies to support its benefits. Authors Kim et al states, “identifying the optimum timing for the initiation of TH is still unknown which calls for further ongoing studies and research into elements of TH in OHCA” (Kim et al., 2015). With the rapid evolution of our technology and the advancement of research, we will soon determine the preferred treatment and clinical intervention for ROSC patients both OHCA or in hospital and the only way for the research to progress is to recognize what our current actions are and how to move away from it and create a better approach in TH.
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Does cooling of ROSC patients in the pre-hospital setting have a better recovery than patients who don't receive pre-hospital coolingardiac Arrest. A randomized Controlled Trial. Circulation 122(7):737-4. C, Dong, J., Zhang, P., Liu, X., & Han, F. (2016). Prehospital therapeutic hypothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis. The American Journal of Emergency Medicine, 34(11), 2209, doi:10.1016/j.ajem.2016.09.007 Cronberg, T., & Lilja, G. (2015). Cognitive decline after cardiac arrest – it is more to the picture than hypoxic brain injury. Resuscitation, 91(Complete), A3-A4. doi:10.1016/j.resuscitation.2015.03.002 Donnino MW, Andersen LW, Berg KM, Reynolds JC, Nolan JP, Morley PT, et al. (2015).Temperature management after cardiac arrest: An advisory statement by the advanced life support task force of the international liaison committee on resuscitation and the American Heart Association Emergency Cardiovascular Care committee and the council on Cardiopulmonary, critical care, perioperative and resuscitation. Circulation. pii: 10.1161/CIR.0000000000000313 Darwazeh, Rami, and Yi Yan. “Mild hypothermia as a treatment for central nervous system injuries: Positive or negative effects?.” Neural Regeneration Research, vol. 8, no. 28, 2013, p. 2677. Academic OneFile, go.galegroup.com.exproxy.lib.ryerson.ca/ps/i.do?
Polderman KH, Rijnsburger ER, Peerdeman SM, Girbes AR. Induction of hypothermia in pa