Targeted Temperature Management

Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham

Pegasus Emergency Group

Is It Still “Cool” to Cool or Is It “Hot” to Not

OR

@PA_Maday #AAPA15

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No Financial Disclosures

Objectives• Discuss history of hypothermia in

acute cardiac events• Evaluate the

advantages/disadvantages of hypothermia in post-arrest management

• Critically evaluate current literature regarding temperature end-points

• Discuss future trends of TTM

History of Hypothermia in Medicine

Hippocratescirca 400 B.C.

Guly H. Resuscitation. 2011;82(1):122-125.

William Osler1890s

The John Hopkins Hospital Reports. Volume V. 1895

Harvey Cushing1920s

1960s - Dr. Peter Safar

Acierno LJ. Clin. Cardiol. 2007;30:52-54.

1971 - Dr. Brian Barrat-Boyes of New Zealand

Barratt-Boyes BG. Circulation. 1971;43(Suppl 5):25-30.

Late 1970s

1980s

85o F (29oC) for days

Mild hypothermia

Numerous complications

Less complications

Case Reports• 1980 - Annals of Internal Medicine– 2 case reports of hypothermic

immersions

Sekar TS. Arch Intern Med. 1980;140(6):775-779.

Severity of Hypothermia

Benefits of Therapeutic Hypothermia

• Lowers tissue oxygen requirements

• Decreases cerebral metabolism and edema

• Improved tolerance to ischemia

• Decreases reperfusion inflammatory cascade Young RSK. JAMA. 1980;244:1233-1235 Globus MY. J Neurochem. 1995;65(4):1704-1711Busto R. Stroke. 1989;28(8):1113-1114

Breakthrough came in 2002

HACA Trial• 275 patients• 32-34o C vs

normothermia for 24 hr

• Primary Outcome– Neurologic function at

6 months

Bernard Trial• 77 patients• 33o vs 37o for 12

hr• Primary Outcome– Favorable

discharge location

HACA Investigators. NEJM. 2002;346(8):549-556. Bernard SA. NEJM. 2002;346(8):557-563.

Results of Initial Hypothermia Trials

HACA Investigators. NEJM. 2002;346(8):549-556. Bernard SA. NEJM. 2002;346(8):557-563.

Trials Criteria MortalityGood

Neurologic Outcomes

HACA

VT/VF rhythmResuscitation within 15minROSC within 60min32-34o for 24hr

Control – 55%Hypothermia – 41%

Control – 39%Hypothermia – 55%

Bernard

VF with persistent coma33o within 2hr for 12hr

Control – 68%Hypothermia – 51%

Control – 26%Hypothermia – 49%

Logistics of Therapeutic Hypothermia

Cooling ApparatiTiming

MedicationsMonitoring

4o C

Artic Sun Cooling System

VELOCITY Trial

Logistics of Therapeutic Hypothermia

Nolan JP. Circulation. 2003;108:118-121

When do you start cooling?

ASAP p ROSCSchwartz BG. Am J Cardio. 2012;110:461-466

Logistics of Therapeutic Hypothermia

Nolan JP. CIrculation. 2003;108:118-121

How long should patients be cooled?

Logistics of Therapeutic Hypothermia

Nolan JP. CIrculation. 2003;108:118-121

How fast do you re-warm?

0.5o/hr to 37o C

Logistics of Therapeutic Hypothermia

Nolan JP. CIrculation. 2003;108:118-121

Medications Monitoring

Hye JK. K J Anes. 2008;54(6):623-628

Prognostication After Therapeutic Hypothermia

Prognosis Following Therapeutic Hypothermia

Taccone FS. Critical Care. 2014;18:202Bouwes A. Ann Neurol. 2012;71(2):206-212

Prognosis Following Therapeutic Hypothermia

Taccone FS. Critical Care. 2014;18:202Bouwes A. Ann Neurol. 2012;71(2):206-212

Complications of Therapeutic Hypothermia

Nolan JP. CIrculation. 2003;108:118-121 Schwartz BG. Am J Cardio. 2012;110:461-466

Targeted Temperature Management

Nielson N. NEJM. 2013;369:2197-2206

Targeted Temperature Management

• 939 patients in 36 ICU across Europe and Australia

• ***ALL RHYTHMS***• 2 study groups• Protocol• Outcomes– Primary – All cause mortality– Secondary – Neurologic status

Nielson N. NEJM. 2013;369:2197-2206

Targeted Temperature Management

Nielson N. NEJM. 2013;369:2197-2206

Outcome 33o Group

36o Group

HR/RR (95% CI)

P-value

Primary OutcomeDeath at end of trial 235/473

(50%)225/466 (48%)

1.06 (0.89-1.28) 0.51

Secondary outcomeNeurologic function at 180d CPC of 3-5 251/469

(54%)242/464 (52%)

1.02 (0.88-1.16) 0.78

MRS of 4-6 245/469 (52%)

239/464 (52%)

1.01 (0.89-1.14) 0.87

Death at 180d 226/473 (48%)

220/466 (47%)

1.01 (0.87-1.15) 0.92

Primary OutcomeNo difference in all-cause mortality

Secondary OutcomeNo difference in neurologic status

Shorter ICU and hospital stays in 36o group

TTM Protocol

1. 24 hours at 36o C2. 12 hours at 37o C3. 36 hours at 37.5o C (de-sedate)4. 36 hours at whatever (no sedation)

Prognosticate after 108 hours following ROSC

What Does This Mean Now?• 33o is not better than 36o

• Not just for VT/VF

• Easier on smaller hospitals

• Decreased hospital LOS

Future Considerations• What temperature is best?

• When to start cooling?

• Duration of cooling?

• Any complications with 36o?

Thank You!maday@uab.edu @PA_Maday

www.pamaday.net