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Background: Recent studies suggest that volatile anaesthetics are safe, efficient, and reliable alternatives to the use of intravenous anaesthetics for out-of-hospital cardiac arrest (OHCA) patients admitted to the intensive care unit (ICU). We hypothesised that volatile anaesthetics may reduce the incidence of delirium rather than intravenous sedatives. This retrospective study aimed to investigate whether sevoflurane combined with higher targeted temperature management could decrease the incidence of delirium when compared with intravenous anaesthetics with lower targeted temperature management.Methods: Using a propensity score-matched analysis, we retrospectively compared a target temperature management (32-34 °C) method along with intravenous sedation (TTM-33/IV) and a modified target temperature management (34-36 °C) method along with sevoflurane sedation (mTTM-36/sevo). We used the confusion assessment method for the ICU to measure the incidence of delirium. We calculated the time-dependent risk on delirium using the multivariate Cox regression model.Results: The incidence of delirium was significantly lower (p = 0.001) in OHCA patients of the mTTM-36/sevo group (9/56, 16.1%) than in those of the TTM-33/IV group (25/67, 37.3%). Mechanical ventilation and lengths of stay in the ICU (p < 0.001) and hospital stay (p = 0.04) were shorter in the mTTM-36/sevo group. Patients in the TTM-33/IV group required more midazolam, propofol, and fentanyl. We observed no significant difference in mortality.Conclusion: A multimodal sevoflurane-based sedation regimen together with targeted temperature management resulted in a lower incidence of delirium and a shorter duration for mechanical ventilation and ICU length of stay than did the treatment with intravenous sedation combined with the classical cooling protocol. [ABSTRACT FROM AUTHOR]

The guidelines on temperature control for comatose cardiac arrest survivors were recently changed from recommending targeted temperature management (32–36 °C) to fever control (≤37.7 °C). We investigated the effect of implementing a strict fever control strategy on prevalence of fever, protocol adherence, and patient outcome in a Finnish tertiary academic hospital. Comatose cardiac arrest survivors treated with either mild device-controlled therapeutic hypothermia (≤36 °C, years 2020–2021) or strict fever control (≤37 °C, year 2022) for the first 36 h were included in this before-after cohort study. Good neurological outcome was defined as a cerebral performance category score of 1–2. The cohort consisted of 120 patients (≤36 °C group n = 77, ≤37 °C group n = 43). Cardiac arrest characteristics, severity of illness scores, and intensive care management including oxygenation, ventilation, blood pressure management and lactate remained similar between the groups. The median highest temperatures for the 36 h sedation period were 36.3 °C (≤36 °C group) vs. 37.2 °C (≤37 °C group) (p < 0.001). Time of the 36 h sedation period spent >37.7 °C was 0.90% vs. 1.1% (p = 0.496). External cooling devices were used in 90% vs. 44% of the patients (p < 0.001). Good neurological outcome at 30 days was similar between the groups (47% vs. 44%, p = 0.787). In multivariable model the ≤37 °C strategy was not associated with any change in outcome (OR 0.88, 95% CI 0.33–2.3). The implementation strict fever control strategy was feasible and did not result in increased prevalence of fever, poorer protocol adherence, or worse patient outcomes. Most patients in the fever control group did not require external cooling. [ABSTRACT FROM AUTHOR]

Aim: To investigate the association of temperature on arrival to hospital after out-of-hospital-cardiac arrest (OHCA) with the primary outcome of mortality, in the targeted temperature management (TTM) trial.Methods: The TTM trial randomized 939 patients to TTM at 33 or 36°C for 24h. Patients were categorized according to their recorded body temperature on arrival and also categorized to groups of patients being actively cooled or passively rewarmed.Results: OHCA patients having a temperature ≤34.0°C on arrival at hospital had a significantly higher mortality compared to the OHCA patients with a higher temperature on arrival. A low body temperature on arrival was associated with a longer time to return of spontaneous circulation (ROSC) and duration of transport time to hospital. Patients who were actively cooled or passively rewarmed during the first 4h had similar mortality. In a multivariate logistic regression model mortality was significantly related to time from OHCA to ROSC, time from OHCA to advanced life support (ALS), age, sex and first registered rhythm. None of the temperature related variables (included the TTM-groups) were significantly related to mortality.Conclusion: OHCA patients with a temperature ≤34.0°C on arrival have a higher mortality than patients with a temperature ≥34.1°C on arrival. A low temperature on arrival is associated with a long time to ROSC. Temperature changes and TTM-groups were not associated with mortality in a regression model. [ABSTRACT FROM AUTHOR]

For more than a decade, mild induced hypothermia (32 °C-34 °C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33 °C or 36 °C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32 °C and 36 °C for at least 24 hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document. [ABSTRACT FROM AUTHOR]

Background Timing of coronary angiography (CAG) is still controversial in the out-of-hospital cardiac arrest survivors who present without ST-segment elevation. Methods and results We analysed a prospective registry of 158 comatose survivors of out-of-hospital cardiac arrest. For further analysis, we included 99 patients without ST-segment elevation on the initial electrocardiogram. All patients underwent temperature management. Urgent CAG (<2 h from admission) was performed in 25% of the patients. A definite cause of the cardiac arrest could be identified during the index hospitalization in 82 patients: 36 had a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and 46 had a non-ACS diagnosis. Eighty-seven patients (88%) survived the index hospitalization and 65 (66%) were alive at six months. A favourable neurological status (cerebral performance category ≤2) was observed in 56% of the patients at discharge and in 56% after six months of follow-up. Neither the survival nor the neurological outcome differed between the patients in whom the CAG was performed urgently upon the admission and the patients in whom the CAG was initially not performed, regardless of the aetiology of the cardiac arrest. On the other hand, performing an urgent CAG was safe and it did not prolong the average time to achieve an effective hypothermia. Conclusions Performing an urgent CAG in comatose cardiac arrest survivors without ST-segment elevation was not associated with better clinical and neurological outcome as compared to the initially conservative approach. [ABSTRACT FROM AUTHOR]