Potentially Life-saving Cooling Treatment Rarely Used for In-hospital Cardiac Arrests: Researchers

by Rukmani Krishna on? June 25, 2013 at 12:13 AM Heart Disease News Researchers from the Perelman School of Medicine at the University of Pennsylvania report in the June issue of Critical Care Medicine that the brain-preserving cooling treatment known as therapeutic hypothermia is rarely being used in patients who suffer cardiac arrest while in the hospital, despite its proven potential to improve survival and neurological function. The authors suggest that scarce data about in-hospital cardiac arrest patients and guidelines that only call for health care providers to consider use of therapeutic hypothermia, rather than explicitly recommending it, may explain the study's results.
In a prospective study between 2003 and 2009 of over 530 hospitals in the United States, the Penn team found that 98 percent of over 67,000 patients who went into cardiac arrest in the hospital received only conventional post-resuscitation care--leaving just 2 percent who received therapeutic hypothermia, which has been credited with saving the lives of a growing number of patients who arrest outside hospitals.

"We know it's being used in patients who went into cardiac arrest in their homes, at work, or anywhere else outside of a hospital, but little was known about how often it's used in patients who arrest in the hospital," said Mark E. Mikkelsen, MD, MSCE, assistant professor in the division of Pulmonology, Critical Care and Allergy at Penn Medicine. "We found that even though most hospitals have the capability to treat these patients with therapeutic hypothermia, it's not being used. And even when it was used, in nearly half the cases, the correct target temperature was not being achieved.

"Several factors could explain this: there is little data, which is often conflicting, to support its use for patients in the hospital, and we have national guidelines that only have clinicians considering its use, which may lead to hesitation and lack of institutional protocol."

Cooling the body down to about 89.6 degrees after cardiac arrest protects it against neurological damage initiated by the lack of blood flow and oxygenation, several studies of out-of-hospital cardiac arrest patients have shown. It has also been shown to improve survival--a welcome development, since cardiac arrest survival statistics remain grim, with less than 10 percent of patients surviving in most cities across the U.S.

More than 300,000 people who go into cardiac arrest out of the hospital die each people each year in the United States; thousands of others are left neurologically devastated.

About 210,000 patients a year go into cardiac arrest while in the hospital--many of those patients may have other conditions that point to a poor prognosis, and a substantial portion may be terminally ill patients who are not candidates for hypothermia.

National recommendations established in 2005 call for out-of-hospital cardiac arrest patients to be treated with hypothermia when they remain comatose after resuscitation. In-hospital recommendations, however, are less direct. The International Liaison Committee on Resuscitation guidelines recommend providers to "consider its use," while the American Heart Association recommends that therapeutic hypothermia "may be considered" for a patient who goes into cardiac arrest caused by non-shockable rhythms.

For the study, the team analyzed treatments of 67,498 patients at 538 hospitals participating in the American Heart Association's Get With the Guidelines-Resuscitation database from 2003 to 2009. Of those patients, 1,367 patients were given therapeutic hypothermia. The use of therapeutic hypothermia increased slightly, from 0.7 percent in 2003 to 3.3 percent in 2009.

Younger patients and patients who were treated in a non-ICU location and a teaching hospital were more likely to get therapeutic hypothermia. Even when it was used, however, target temperature (32-34o Celsius, or 89.6-93.2 degrees Fahrenheit ) was not achieved in 44.3 percent of the patients within 24 hours, and 17.6 percent were overcooled.

"These rates are particularly important to examine, given that the incidence of in hospital events appears to be increasing," said Dr. Mikkelsen. "I believe there is potential for therapeutic hypothermia to benefit this population, but traction can only be made after clinical trials investigating safety and effectiveness are initiated-which are certainly warranted. Results of those studies could strengthen the case for stronger recommendations and increase use."

Source-Eurekalert

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ECMO may Now be Used to Treat Cardiac Arrest

ECMO directly oxygenates and removes carbon dioxide from the blood, and is conventionally used for both respiratory and cardiac failure. The procedure requires 24/7 monitoring and care for the duration of the treatment, but provides a critical back-up for patients whose heart and lungs are so severely diseased or damaged that they can no longer function.

"Over the last decade, we have made great strides in the field of cardiac resuscitation science, including the development of novel methods of therapeutic hypothermia and the use of cardiac bypass following cardiac arrest," said lead study author David Gaieski, MD, an associate professor of Emergency Medicine in the Perelman School of Medicine and clinical director of Penn''s Center for Resuscitation Science. "Yet cardiac arrests still take the lives of more than 300,000 Americans each year, and we are continuing to explore how to use new and expanded strategies to help save these patients. Based on the work of our colleagues in Asia, we sought to report our own experience using ECMO for a select set of patients with refractory cardiac arrest and profound shock."

For the study, the research team used a collaborative approach between clinicians in the Department of Emergency Medicine and surgeons within the Division of Cardiovascular Surgery at Penn to assess the outcomes for select patients undergoing ECMO presenting in the emergency department (ED) and for in-hospital cardiac arrests at the Hospital of the University of Pennsylvania.

They studied the approach in patients who otherwise would have died - who were unable to be resuscitated through CPR and defibrillation and who would not have been eligible for other post-arrest therapies such as therapeutic hypothermia.

Inclusion criteria for ED patients included witnessed arrest, bystander CPR, and an initial shockable rhythm. For in-patient arrests, inclusion criteria included presumed cardiac etiology of arrest or refractory shock unresponsive to conventional interventions. Main variables were whether a patient was in cardiac arrest or profound shock and location of patient at time of initiation of ECMO, with the primary outcome of survival to hospital discharge.

Thirty-three patients were included in the study. Of these patients, the mean age was 50 years and 70 percent were men. Three-quarters of the patients were treated for cardiac arrest, and the remainder were treated for refractory shock. Using the ECMO strategy, 21 percent of the patients survived to discharge and five were neurologically intact.

"This preliminary study shows that using ECMO in a collaborative model between emergency physicians and cardiothoracic surgeons can be a useful rescue tool in select cardiac arrest and shock patients. The results are promising given that among patients that regain a pulse after cardiac arrest, only one out of three survive to hospital discharge," said senior study author Michael Acker, MD, chief, Division of Cardiovascular Surgery at Penn Medicine.

The authors note that because ECMO is a resource-intense technology which requires procedural and management expertise, additional research is needed to refine the technique and select the patients that would benefit most from this intervention. Next, the authors hope to study the use of ECMO in conjunction with therapeutic hypothermia to improve neurological outcomes among survivors of cardiac arrest.

Additional authors from Penn include Nicholas Johnson, MD, Cindy H. Hsu, MD, PhD, Lance B. Becker, MD, Anne V. Grossestreuer, Doreen Cowie, and Marion Leary, BSN, RN.

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Penn Medicine is one of the world''s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation''s first medical school) and the University of Pennsylvania Health System, which together form a $4.3 billion enterprise.

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 16 years, according to U.S. News & World Report''s survey of research-oriented medical schools. The School is consistently among the nation''s top recipients of funding from the National Institutes of Health, with $398 million awarded in the 2012 fiscal year.

The University of Pennsylvania Health System''s patient care facilities include: The Hospital of the University of Pennsylvania -- recognized as one of the nation''s top "Honor Roll" hospitals by U.S. News & World Report; Penn Presbyterian Medical Center; and Pennsylvania Hospital -- the nation''s first hospital, founded in 1751. Penn Medicine also includes additional patient care facilities and services throughout the Philadelphia region.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2012, Penn Medicine provided $827 million to benefit our community.

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