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VOLUME 26 , ISSUE 4 ( April, 2022 ) > List of Articles

Systematic Review/Meta Analysis

Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Arun Rath, Samir Samal, Abhilash Dash, Biswajit Nayak

Keywords : Hypothermia, Mortality, Neurological outcome, Normothermia, Post cardiac arrest, Targeted temperature management

Citation Information : Rath A, Samal S, Dash A, Nayak B. Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022; 26 (4):508-515.

DOI: 10.5005/jp-journals-10071-24173

License: CC BY-NC 4.0

Published Online: 13-05-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Background: Targeted temperature management (TTM) is a vital element of postresuscitation management after cardiac arrest. Though international guidelines recommend TTM, the supporting evidence is of low certainty. Aims and objectives: To estimate the effect of TTM strategy on mortality and neurological outcomes in postcardiac arrest survivors. Materials and methods: Randomized controlled trials (RCTs) published in English evaluating the use of TTM in adult comatose survivors of cardiac arrest were included. Studies were categorized into two groups, based on hypothermia vs normothermia. The main outcome was death due to any origin. The secondary outcome measures evaluated neurological outcome and complications associated with TTM. Outcomes were analyzed by calculating Odds Ratio (OR) of a worse outcome. ORs with 95% CIs in a forest plot were used to show the results of random-effects meta-analyses. Results: On pooled analysis of 11 RCTs, no difference was observed in death due to any origin rates in the hypothermia compared to the normothermia group (OR; 0.88, 95% CI: 0.39–1.16). Overall, no difference in poor neurological outcome was observed between the two groups (OR; 0.86, 95% CI: 0.66–1.12). Trial sequencing analysis for mortality and poor neurological outcome showed that number to achieve power to predict futility has been achieved in both the parameters. Conclusions: This meta-analysis showed that hypothermia compared to normothermia TTM strategies does not improve survival or neurologic outcomes.


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  1. Nolan JP, Sandroni C, Bottiger B W, Cariou A, Cronberg T, Friberg H, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021;47(4):369–421. DOI: 10.1007/s00134-021-06368-4.
  2. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020;142 (16_suppl_2):S366–S468. DOI: 10.1161/CIR.0000000000000916.
  3. Holzer M, Cerchiari E, Martens P, Roine R, Sterz F, Eisenburger P, et al. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346(8):549–556. DOI: 10.1056/NEJMoa012689.
  4. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced Hypothermia. N Engl J Med 2002;346(8):557–563. DOI: 10.1056/NEJMoa003289.
  5. Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Bottiger BW, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, Inter American Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008;118(23):2452–2483. DOI: 10.1161/CIRCULATIONAHA.108.190652.
  6. Parrillo JE, Dellinger RP. Critical care medicine. Principles of diagnosis and management in the adult. 5th ed. Elsevier: Philadelphia; 2019.
  7. Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European resuscitation council guidelines for resuscitation 2015. Resuscitation 2015;95:202–222. DOI: 10.1016/j.resuscitation.2015.07.018.
  8. Lascarrou JB, Merdji H, Le Gouge A, Colin G, Grillet G, Girardie P, et al. Targeted temperature management for cardiac arrest with non-shockable rhythm. N Engl J Med 2019;381(24):2327–2337. DOI: 10.1056/NEJMoa1906661.
  9. Dankiewicz J, Cronberg T, Lilja G, Jakobsen JC, Levin H, Ullen S, et al. Targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM-2). N Engl J Med 2021;384:2283–2294. DOI: 10.1056/NEJMoa2100591.
  10. Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management 33°C versus 36°C after cardiac arrest. N Engl J Med 2013;369(23):2197–2206. DOI: 10.1056/NEJMoa1310519.
  11. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. British Medical. Journal 2021;372:n71. DOI: 10.1136/bmj.n71.
  12. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical. Journal 2008;336(7650):924–926. DOI: 10.1136/bmj.39489.470347.AD.
  13. Santesso N, Glenton C, Dahm P, Garner P, Akl EA, Alper B, et al. GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. J Clin Epidemiol 2020;119:126–135. DOI: 10.1016/j.jclinepi.2019.10.014.
  14. Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis. J Clin Epidemiol 2008;61(1):64–75. DOI: 10.1016/j.jclinepi.2007.03.013.
  15. Thorlund K, Devereaux PJ, Wetterslev J, Guyatt G, Ioannidis JP, Thabane L, et al. Can trial sequential monitoring boundaries reduce spurious inferences from meta-analyses? Int J Epidemiol 2009;38(1):276–286. DOI: 10.1093/ije/dyn179.
  16. Mori K, Takeyama Y, Itoh Y, Nara S, Yoshida M, Ura H, et al. A multivariate analysis of prognostic factors in survivors of out of out-of-hospital cardiac arrest with brain hypothermia. Crit Care Med 2000;28(12):A168.
  17. Hachimi-Idrissi S, Corne L, Ebinger G, Michotte Y, Huyghens L. Mild hypothermia induced by a helmet device: a clinical feasibility study. Resuscitation 2001;51(3):275–281. DOI: 10.1016/s0300- 9572(01)00412-9.
  18. Hachimi-Idrissi S, Zizi M, Nguyen DN, Schiettecate J, Ebinger G, Michotte Y, et al. The evolution of serum astroglial S-100 beta protein in patients with cardiac arrest treated with mild Hypothermia. Resuscitation 2005;64(2):187–192. DOI: 10.1016/j.resuscitation.2004.08.008.
  19. Laurent I, Adrie C, Vinsonneau C, Cariou A, Chiche JD, Ohanessian A, et al. High-volume hemofiltration after out-of-hospital cardiac arrest: a randomized study. J Am Coll Cardiol 2005;46(3):432–437. DOI: 10.1016/j.jacc.2005.04.039.
  20. Kamarainen A, Virkkunen I, Tenhunen J, Yli-Hankala A, Silfvast T. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomised controlled trial. Acta Anaesthesiol Scand 2009;53(7):900–907. DOI: 10.1111/j.1399-6576.2009.02015.x.
  21. Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. Journal of the American Medical Association 2014;311(1):45–52. DOI: 10.1001/jama.2013.282173.
  22. Salter R, Bailey M, Bellomo R, Eastwood G, Goodwin A, Nielsen N, et al. Changes in temperature management of cardiac arrest patients following publication of the target temperature management trial. Crit Care Med 2018;46(11):1722–1730. DOI: 10.1097/CCM.0000000000003339.
  23. Nolan JP, Orzechowska I, Harrison DA, Soar J, Perkins GD, Shankar-Hari M. Changes in temperature management and outcome after out-of-hospital cardiac arrest in United Kingdom intensive care units following publication of the targeted temperature management trial. Resuscitation 2021;162:304–311. DOI: 10.1016/j.resuscitation.2021.03.027.
  24. Taccone FS, Picetti E, Vincent JL. High quality targeted temperature management (TTM) after cardiac arrest. Crit Care 2020;24(1):6. DOI: 10.1186/s13054-019-2721-1.
  25. Arrich J, Holzer M, Havel C, Mullner M, Herkner H. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2012;9:CD004128. DOI: 10.1002/14651858.CD004128.pub4.
  26. Kim YM, Yim HW, Jeong SH, Klem ML, Callaway CW. Does therapeutic Hypothermia benefit adult cardiac arrest patients presenting with non-shockable initial rhythms?: A systematic review and meta-analysis of randomised and non-randomised studies. Resuscitation 2012;83(2):188–196. DOI: 10.1016/j.resuscitation.2011.07.031.
  27. Zhang XW, Xie JF, Chen JX, Huang YZ, Guo FM, Yang Y, et al. The effect of mild induced Hypothermia on outcomes of patients after cardiac arrest: a systematic review and meta-analysis of randomised controlled trials. Crit Care 2015;19:417. DOI: 10.1186/s13054-015- 1133-0.
  28. Bhattacharjee S, Baidya DK, Maitra S. Therapeutic hypothermia after cardiac arrest is not associated with favorable neurological outcome: a meta-analysis. J Clin Anesth 2016;33:225–232. DOI: 10.1016/j.jclinane.2016.03.001.
  29. Kalra R, Arora G, Patel N, Doshi R, Berra L, Arora P, et al. Targeted temperature management after cardiac arrest: systematic review and meta-analyses. Anesth Analg 2018;126(3):867–875. DOI: 10.1213/ANE.0000000000002646.
  30. Villablanca PA, Makkiya M, Eisenberg E, Briceno DF, Panagiota C, Menegus M, et al. Mild therapeutic hypothermia in patients resuscitated from out-of-hospital cardiac arrest: a meta-analysis of randomized controlled trials. Ann Card Anaesth 2016;19(1):4–14. DOI: 10.4103/0971-9784.173013.
  31. Fernando SM, Di Santo P, Sadeghirad B, Lascarrou JB, Rochwerg B, Mathew R, et al. Targeted temperature management following out-of-hospital cardiac arrest: a systemic review and network meta-analysis of temperature targets. Intensive Care Med 2021;47(10): 1078–1088. DOI: 10.1007/s00134-021-06505-z.
  32. Kongpolprom N, Cholkraisuwat J. Neurological prognostications for the therapeutic hypothermia among comatose survivors of cardiac arrest. Indian J Crit Care Med 2018;22(7):509–518. DOI: 10.4103/ijccm.IJCCM_500_17.
  33. Saigal S, Sharma JP, Dhurwe R, Kumar S, Gurjar M. Targeted temperature management: current evidence and practices in critical care. Indian J Crit Care Med 2015;19(9):537–546. DOI: 10.4103/0972-5229.164806.
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