Intra-arrest therapeutische hypothermie Fabienne Roossien, AIOS SEH Regionaal refereren 18-07-2013

Inhoud Achtergrond Search Studies Conclusie Discussie THM

Achtergrond Dierstudies: Veilig, uitvoerbaar 5-7 Effect mensen? Intra-arrest TH 1-4 : betere kans op ROSC & survival betere neurologische uitkomst Veilig, uitvoerbaar 5-7 Effect mensen?

Search

Search Embase 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) Rest niet bruikbaar want: review, geen beantwoording mijn vraag

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 arrest Resuscitation 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 etiology Circulation 2011 124: A97& A2 Castren et al. Earlier intra-arrest transnasal cooling may be beneficial Critical care 2011, 15(suppl):P303

IATH d.m.v. trans-nasal cooling Auteur Patient groep Studie type Inter-ventie Vergelijking Outcomes Resultaten Study Weaknessess Level Castren et al. 2010 194ptn>18jr met OHCA 93 IATH 101 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 Safety: Adverse events<24hr Serious adverse events <7dgn Adverse events: -witte neus -3 ptn epistaxis Serious<7d: 7 IATH 14 controle

Auteur Patient groep Studie type Inter-ventie Vergelijking Outcomes Resultaten Study Weaknessess Level Garret et al. 2011 542 ptn >18jr met OHCA 208 IATH 334 niet Retrospectief History-control Intra-arrest TH: 2L 4gr NaCl 0,9% Max. 2L Intra-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 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 8040 OHCA (cardiale oorzaak) 4459 control 3581 TH Retro-spectief History control 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 Abstract Retrospectief Groepen verschillend moment behandeld ntb 10309 OHCA (niet trauma) 5582 control 4727 TH “ 8,3% vs. 9,5% witnessed arrest (p0,026) 31,7% vs. 29% ROSC (p<0,003) 24,1% vs. 21,9% (p<0,0014)

Auteur Patient groep Studie type Inter-ventie Vergelijking Outcomes Resultaten Study Weaknessess Level Castren 2011 41 ptn met OHCA 19 IATH 22 control Prospectief RCT IATH d.m.v. trans-nasal cooling (Rhino chill) Geen IATH ROSC rate ROSC IATH 42% vs 36% control Site 1: cooling @ 11 min 50% IATH vs 11% control (CPR IATH 5min vs 7min control) Site 2: cooling@20min 39% 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: Positief effect geen adverse events, IATH haalbaar, neiging naar meer ROSC Positief effect Echter: veilig en haalbaar, dus… Keep it cool & fast!

Vragen?

Referenties Nozari et al. Critical time window for intra-arrest cooling with cold-saline flush in a dog model of CPR Circulation 2006; 113; 2690-6 Zhao et al. Intra-arrest cooling with delayed reperfusion yields higher survival than earier normothermic resuscitatoion in a mouse-model. Resuscitation 2008; 77:242-9 Abella et al. Intra-arrest cooling improves outcomes in a murine cardiac arrest model. Circulation 2004; 109:2786-91 Menegazzi et al Effects of pre-arrest and intra-arrest hypothermia on ventricular defirillation and resuscitation Resuscitation 2009; 80:126-32 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. 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. 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. Castren et al. Intra-arrest transnasalevaporative 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 arrest Resuscitation 82 (2011) 21–25 Scolletta et al. Intra-arrest hypothermia during cardiac arrest: a systematic review. Critical Care 2012, 16:R41 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 Freese Intra-arrest Induction of Therapeutic Hypothermia via Large-Volume Ice-Cold Saline Infusion Improves Immediate Outcomes for Out-of-Hospital Cardiac Arrest Castren et al . Earlier intra-arrest transnasal cooling may be beneficial Critical care 2011, 15(suppl):P303