Koelen van patiënten na een hartstilstand buiten het ziekenhuis

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Het koelen van patienten na een hartstilstand buiten het ziekenhuis, belangrijke onderzoeken, conclusie spreekt boekdelen.

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest

Background
Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. Our objective was to compare two target temperatures, both intended to prevent fever.


Methods
In an international trial, we randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale.

Results
In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.

Conclusions
In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C. (Funded by the Swedish Heart–Lung Foundation and others; TTM ClinicalTrials.gov number, NCT01020916.)


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Zie ook http://www.hulpverleningsforum.nl/index.php?topic=68599.0

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Pre-Hospital Hypothermia for OHCA

In adults with out-of-hospital cardiac arrest, prehospital cooling decreased the mean core temperature in patients with and without ventricular fibrillation (VF), and reduced the time to achieve a temperature of less than 34°C, but did not improve the primary outcomes of survival or neurological status at discharge, according to results of the Induction of Mild Hypothermia Following Out-of-Hospital Cardiac Arrest trialpresented Nov. 17 as part of AHA 2013, and published simultaneously in the Journal of the American Medical Association.

The trial randomized 1,359 adults "with prehospital cardiac arrest to standard care with or without prehospital cooling, accomplished by infusing up to 2 L of 4°C normal saline as soon as possible following return of spontaneous circulation." Results showed "survival to hospital discharge was similar among the intervention and control groups among patients with VF (62.7 percent [95 percent CI, 57.0 percent - 68.0 percent] vs. 64.3 percent [95 percent CI, 58.6 percent -69.5 percent], respectively; P = .69) and among patients without VF (19.2 percent [95 percent CI, 15.6 percent - 23.4 percent] vs. 16.3 percent [95 percent CI, 12.9 percent - 20.4 percent], respectively; P = .30)."

Further, "the intervention was also not associated with improved neurological status of full recovery or mild impairment at discharge for either patients with VF (57.5 percent [95 percent CI, 51.8 percent - 63.1 percent] of cases had full recovery or mild impairment vs. 61.9 percent [95 percent CI, 56.2 percent - 67.2 percent] of controls; P = .69) or those without VF (14.4 percent [95 percent CI, 11.3 percent - 18.2 percent] of cases vs. 13.4 percent [95 percent CI, 10.4 percent -17.2 percent] of controls; P = .30)."

The authors add that "the intervention decreased mean core temperature by 1.20°C (95 percent CI, -1.33°C to -1.07°C) in patients with VF and by 1.30°C (95 percent CI, -1.40°C to -1.20°C) in patients without VF by hospital arrival and reduced the time to achieve a temperature of less than 34°C by about 1 hour compared with the control group."

"Under the conditions of our study, early cooling in the field didn't improve neurologic outcomes or survival following resuscitation from out-of-hospital cardiac arrest," said Francis Kim, MD, FACC, lead author of the study and an associate professor of medicine in the cardiology division of the University of Washington in Seattle.

The authors conclude that "although hypothermia is a promising strategy to improve resuscitation and brain recovery following cardiac arrest, the results of the current study do not support routine use of cold intravenous fluid in the prehospital setting to improve clinical outcomes."

An editorial comment by Christopher B. Granger, MD, FACC, of the Duke Clinical Research Institute, Durham, North Carolina, and Lance B. Becker, MD, of the Center for Resuscitation Science, University of Pennsylvania Health System, Philadelphia, notes that based on the study results, "emergency medical servicesagencies should concentrate on other means to improve survival from cardiac arrest. These include optimizing dispatch processes, ensuring quality cardiopulmonary resuscitation, transporting of patients to hospitals capable of providing quality cardiac arrest care, and measuring and continuously improving quality measures of cardiac arrest care."

They caution that the study results "should not be extended to use of other methods of hypothermia initiated in the emergency department or continued during the initial phase of postresuscitation care in the intensive care unit." They add that moving forward, "more trials are needed to answer vital questions regarding the use of hypothermia."

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Beetje koelen na reanimatie volstaat
Na een hartstilstand is het niet nodig om patiënten tot 33 graden te koelen. Koelen tot 36 graden is net zo effectief. Dit stellen Niklas Nielsen e.a. in de New England Journal of Medicine op basis van een internationaal multicenteronderzoek.

De onderzoekers includeerden 950 patiënten die op de ic terechtkwamen na een hartstilstand die buiten het ziekenhuis was ontstaan. Bij hen werden twee koelstrategieën vergeleken. De koudste aanpak had geen voordeel boven de 36-gradenaanpak als het ging om mortaliteit of neurologische uitkomst.

Eerder onderzoek liet zien dat koelen tot 32-34 graden het neurologisch functioneren en de mortaliteit wel positief beïnvloedde
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Voortaan dus maar een dun lakentje ipv een dikke ambulancedeken  

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Mijn langste reanimatie ooit (+2uur) met perfecte outcome was van iemand die in een ijskoude winter in het kanaal gereden was met zijn fiets dus onderkoeld alvorens in stilstand. Enige nadeel is dat tijdens het opwarmen tijdens het transport hij elke schok van de weg in VKF ging.