Mejora del pronóstico tras parada cardiorrespiratoria de causa cardiaca mediante el empleo de hipotermia moderada: comparación con un grupo control

doi:10.1016/S0300-8932(09)71686-0

Revista Española de Cardiología

Volume 62, Issue 7, July 2009, Pages 733-741

https://doi.org/10.1016/S0300-8932(09)71686-0 Get rights and content

Introducción y objetivos

Los pacientes que sobreviven a una parada cardiaca tienen mal pronóstico vital y neurológico a corto plazo. La hipotermia moderada se ha ensayado en escasos estudios aleatorizados y parece ser eficaz en el tratamiento de estos pacientes. Nuestro objetivo es mostrar el impacto de esta estrategia en la supervivencia y en el estado neurológico.

Métodos

Hemos comparado hipotermia frente a tratamiento habitual en pacientes tras parada cardiaca prolongada por fibrilación o taquicardia ventricular y con signos de daño neurológico, para lo que se establecieron un grupo control de 28 pacientes y otro grupo de 41 pacientes tratados con hipotermia. Los pacientes fueron evaluados al alta y a los 6 meses.

Resultados

No se encontraron diferencias significativas entre los grupos al comparar las características basales, las características de la parada y los tiempos de asistencia. Al alta tenían una buena situación neurological 18 (43,9%) pacientes del grupo de hipotermia y 5 (17,9%) del grupo control (riesgo relativo [RR] = 2,46; intervalo de confianza [IC] del 95%, 1,11-3,98; p = 0,029). A los 6 meses del alta, se encontraban en buena situación neurológica 19 (46,3%) pacientes del grupo tratado y 6 (21,4%) del grupo control (RR = 2,16; IC del 95%, 1,05-3,36; p = 0,038). El efecto de la hipotermia puede verse afectado por diversos factores de confusión.

Conclusiones

Nuestros resultados ponen de manifiesto que el tratamiento con hipotermia después de parada cardiaca prolongada por FV o TV contribuye a mejorar el pronóstico de la encefalopatía anóxica.

Introduction and objectives

Patients who survive a cardiac arrest have a poor short-term prognosis in terms of mortality and neurological function. The use of mild hypothermia has been investigated in only a few randomized studies, but appears to be effective for treating these patients. The aim of this study was to investigate the effect of this treatment on survival and neurological outcomes.

Methods

We compared mild hypothermia and usual treatment in patients who had experienced a prolonged cardiac arrest due to ventricular fibrillation or tachycardia and who showed signs of neurological damage. Patient were divided into two groups: a control group of 28 patients and a group of 41 patients who were treated with hypothermia. Patients were assessed at discharge and at 6 months.

Results

There was no significant difference between the two groups in baseline characteristics, including those of the cardiac arrest, or in the time to treatment. At discharge, neurological status was good in 18 patients (43.9%) in the hypothermia group but in only five (17.9%) in the control group (risk ratio=2.46; 95% confidence interval, 1.11-3.98; P=.029). At 6 months after discharge, neurological status was found to be good in 19 patients (46.3%) in the treatment group and six (21.4%) in the control group (risk ratio=2.16; 95% confidence interval, 1.05-3.36; P=.038). The effect of hypothermia may have been affected by various confounding factors.

Conclusions

Our findings demonstrate that hypothermic treatment after cardiac arrest prolonged by ventricular fibrillation or tachycardia helps improve the prognosis of anoxic encephalopathy.

Section snippets

INTRODUCIÓN

La supervivencia tras una parada cardiorrespiratoria (PCR) extrahospitalaria depende del tipo de asistencia inicial, y puede llegar a un 16-32% en los casos presenciados y asistidos de inmediato, pero se reduce enormemente si no es así¹. El trastorno del ritmo cardiaco que origina la PCR determina la supervivencia, que es de hasta un 34% en caso de fibrilación ventricular (FV), pero no más del 6% en caso de asistolia de disociación electromecánica (DEM)^2,³.

La importancia de disminuir el daño

Sujetos de estudio

El estudio se ha llevado a cabo en nuestra unidad coronaria, que consta de 11 camas. La población estudiada comprende a todos los pacientes que han ingresado entre enero de 2000 y mayo de 2008 con el diagnóstico de PCR extrahospitalaria o intrahospitalaria. Se han empleado los siguientes criterios de inclusión: FV o taquicardia ventricular (TV) sin pulso como primer ritmo, maniobras de reanimación cardiopulmonar (RCP) avanzada prolongadas con necesidad de intubación orotraqueal, resucitación

Selección de los pacientes del estudio

En el periodo de estudio han ingresado en nuestra unidad coronaria 133 pacientes con el diagnóstico de PCR extrahospitalria o intrahospitalaria. De este grupo total, se excluyó a 20 (15%) por tratarse de episodios de FV con cardioversión exitosa sin necesidad RCP prolongada, 25 (18,8%) en los que el primer ritmo fue DEM o asistolia, 7 (5,3%) con parada respiratoria por neumopatía severa, 3 (2,2%) en coma farmacológico y Glasgow > 8 una vez eliminado el efecto de los sedantes, 2 (1,5%) con una

DISCUSIÓN

En nuestra unidad coronaria se realiza HM a pacientes tras parada cardiaca por FV o TV desde 2002 y de forma protocolizada desde 2003. Se trata de una técnica poco extendida en nuestro país y nuestra serie es la más amplia experiencia publicada en España hasta la fecha.

El análisis retrospectivo de nuestros resultados podría avalar la utilización de esta técnica en la línea de lo previamente mostrado en los ensayos aleatorizados^7,^8,¹³: beneficio en cuanto al pronóstico neurológico y notable

CONCLUSIONES

La HM es una técnica terapéutica que contribuye a mejorar el pronóstico vital y neurológico de los pacientes tras PCR prolongada por FV o TV, y se han publicado recomendaciones específicas sobre su empleo. No obstante, la efectividad de la técnica parece ser muy dependiente de diversos factores, de los que los más determinantes son el tratamiento de la causa de la parada (especialmente si se trata de infarto agudo de miocardio) y la precocidad en el inicio de maniobras de reanimación. Por ello,

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Cited by (44)

Management of temperature control in post-cardiac arrest care: an expert report
2021, Medicina Intensiva
Actualmente, el control estricto de temperatura mediante hipotermia inducida (entre 32 y 36 ^oC) se considera un tratamiento de primera línea en el manejo de pacientes con parada cardiaca recuperada que ingresan en Unidades de Cuidados Intensivos. Su objetivo es disminuir el daño neurológico secundario a anoxia cerebral. Aunque existen múltiples evidencias sobre sus beneficios, el empleo de esta técnica en nuestro país es pobre y todavía existen temas controvertidos como temperatura óptima, velocidad de instauración, duración y proceso de calentamiento. El objetivo de este trabajo es desarrollar la evidencia científica actual y las recomendaciones de las principales guías internacionales. El enfoque de este documento se centra también en aplicación práctica del control estricto de la temperatura en la parada cardiaca recuperada en nuestras Unidades de Cuidados Intensivos Generales o Cardiológicas, principalmente en los métodos de aplicación, protocolos, manejo de las complicaciones y elaboración del pronóstico neurológico.
Targeted temperature management (TTM) through induced hypothermia (between 32-36 ^oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.
Characteristics and evolution of patients with out of hospital cardiac arrest treated with therapeutic hypothermia
2017, Cardiocore
La parada cardiorrespiratoria (PCR) presenta múltiples morbilidades secundarias, especialmente las neurológicas, por tanto es necesario un correcto manejo posparada. El objetivo de este trabajo consiste en analizar las características y los resultados de pacientes sometidos a hipotermia tras una PCR extrahospitalaria resucitada.
Realizamos un estudio prospectivo observacional de dos años, donde se incluyeron pacientes que ingresaron en nuestra unidad mayores de 18 años y con PCR prolongada extrahospitalaria resucitada, en los cuales se realizó un protocolo consensuado de cuidados posresucitación e hipotermia terapéutica.
Se incluyeron 33 pacientes. Se observó una media de 31,6 min de tiempo de PCR. Un 32,3% presentaron encefalopatía hipóxico-anóxica, siendo más frecuente en fumadores (p = 0,04), y con mayores tiempos de PCR (p= 0,049). También el 66,7% de los pacientes presentaron mayores datos de hipoperfusión (p = 0,049).
Observamos que la hipotermia podría ser un instrumento útil en el manejo de las PCR extrahospitalarias. Además, encontramos que el pronóstico neurológico se asocia más a factores no modificables.
Cardiac arrest have secondary co-morbidities, especially neurological outcome. Due to this cirumstances is mandatory to optimized postcardiac arrest management. The objective of this research is to analyze patient's characteristics and outcome after out-hospital cardiac arrest in patients that have undergone therapeutic hypothermia.
We conducted a prospective observational study during a two-year period. We included resuscitated patients over eighteen years old who were admitted in to our intensive care unit. These patients had undergone prolonged resuscitation measures and were included in an implemented post-resuscitation protocol which included therapeutic hypothermia.
Thirty-three patients were analyzed. The median time of cardiopulmonary resuscitation was 31.6 minutes. We observed hypoxic/anoxic encephalopathy in 32.3% of cases. This prognosis was associated in those who smoked (p = .04) and with longer time of cardiac arrest (p = .049). Also, the 66.7% of the patients showed a higher incidence of hypoperfusion (p = .049).
In our series hypothermia could be a useful tool in post-resucitation cardiac arrest managment. We also found that the neurological prognosis was associated to non-modifiable risk factors.
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.
2015, Resuscitation
Citation Excerpt :
Cooling blankets or pads.221–227 Water or air circulating blankets.7,8,10,182,226,228–234 Water circulating gel-coated pads.7,224,226,233,235–238
What should be done with survivors of a cardiac arrest? induce hypothermia or just avoid hyperthermia?
2015, Revista Espanola de Cardiologia
Therapeutic hypothermia after in-hospital cardiac arrest: A critique
2014, Journal of Cardiothoracic and Vascular Anesthesia
More than 210,000 in-hospital cardiac arrests occur annually in the United States. Use of moderate therapeutic hypothermia (TH) in comatose survivors after return of spontaneous circulation following out-of-hospital cardiac arrest (OOH-CA) caused by ventricular fibrillation or pulseless ventricular tachycardia is recommended strongly by many professional organizations and societies. The use of TH after cardiac arrest associated with nonshockable rhythms and after in-hospital cardiac arrest (IH-CA) is recommended to be considered by these same organizations and is being applied widely. The use in these latter circumstances is based on an extrapolation of the data supporting its use after out-of-hospital cardiac arrest associated with shockable rhythms.
The purpose of this article is to review the limitations of existing data supporting these extended application of TH after cardiac arrest and to suggest approaches to this dilemma. The data supporting its use for OOH-CA appear to this author, and to some others, to be rather weak, and the data supporting the use of TH for IH-CA appear to be even weaker and to include no randomized controlled trials (RCTs) or supportive observational studies. The many reasons why TH might be expected to be less effective following IH-CA are reviewed. The degree of neurologic injury may be more severe in many of these cases and, thus, may not be responsive to TH as currently practiced following OOH-CA. The potential adverse consequences of the routine use of TH for IH-CA are listed and include complications associated with TH, interference with diagnostic and interventional therapy, and use of scarce personnel and financial resources. Most importantly, it inhibits the ability of researchers to conduct needed RCTs. The author believes that the proper method of providing TH in these cases needs to be better defined.
Based on this analysis the author concludes that TH should not be used indiscriminantly following most cases of IH-CA, and instead clinicians should concentrate their efforts in conducting high-quality large RCTs or large-scale, well-designed prospective observation studies to determine its benefits and identify appropriate candidates.
Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients
2013, Resuscitation
Neuromuscular blockade may improve outcomes in patients with acute respiratory distress syndrome. In post-cardiac arrest patients receiving therapeutic hypothermia, neuromuscular blockade is often used to prevent shivering. Our objective was to determine whether neuromuscular blockade is associated with improved outcomes after out-of-hospital cardiac arrest.
A post hoc analysis of a prospective observational study of comatose adult (>18 years) out-of-hospital cardiac arrest at 4 tertiary cardiac arrest centers. The primary exposure of interest was neuromuscular blockade for 24 h following return of spontaneous circulation and primary outcomes were in-hospital survival and functional status at hospital discharge. Secondary outcomes were evolution of oxygenation (PaO₂:FiO₂), and change in lactate. We tested the primary outcomes of in-hospital survival and neurologically intact survival with multivariable logistic regression. Secondary outcomes were tested with multivariable linear mixed-models.
A total of 111 patients were analyzed. In patients with 24 h of sustained neuromuscular blockade, the crude survival rate was 14/18 (78%) compared to 38/93 (41%) in patients without sustained neuromuscular blockade (p = 0.004). After multivariable adjustment, neuromuscular blockade was associated with survival (adjusted OR: 7.23, 95% CI: 1.56–33.38). There was a trend toward improved functional outcome with neuromuscular blockade (50% versus 28%; p = 0.07). Sustained neuromuscular blockade was associated with improved lactate clearance (adjusted p = 0.01).
We found that early neuromuscular blockade for a 24-h period is associated with an increased probability of survival. Secondarily, we found that early, sustained neuromuscular blockade is associated with improved lactate clearance.

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Introducción y objetivos

Métodos

Resultados

Conclusiones

Introduction and objectives

Methods

Results

Conclusions

Section snippets

INTRODUCIÓN

Sujetos de estudio

Selección de los pacientes del estudio

DISCUSIÓN

CONCLUSIONES

J Emerg Med

Resuscitation

Am J Med

Ann Emerg Med

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Int J Cardiol

Resuscitation

Cardiac resuscitation

N Engl J Med

The Multi-Society Task Force on PVS

N Engl J Med