Abstract 106 - Care for cardiac arrest patients treated with
hypothermia may be withdrawn too soon
Cardiac arrest patients treated with hypothermia may achieve
neurological awakening that's not apparent for a week - several
days after physicians routinely make recommendations about whether
to withdraw care, researchers said.
For more than 25 years, the prognosis for recovery from cardiac
arrest and the decision to withdraw care has been based on a
neurological exam at 72 hours. So the finding may have profound
implications on when withdrawal-of-care decisions will be made for
these patients.
Researchers evaluated 47 patients who survived non-traumatic
out-of-hospital cardiac arrest and were admitted to an academic
medical center. Fifteen patients received therapeutic hypothermia
(cooling the body to 33 degrees Celsius, 91.4 degrees Fahrenheit).
Seven of them (46.6 percent) survived to discharge. Of the 32
patients who received conventional care (no hypothermia), 13 (40.6
percent) survived to discharge.
Brain activity level was assessed daily in all patients:
- Within three days, 38.5 percent of patients receiving
conventional care were alert after resuscitation and considered to
have mild deficits.
- At day three, no hypothermia patients were alert and
conscious.
- At day seven, 33 percent of hypothermia patients had regained
alertness and were considered to have mild deficits.
- At discharge, 83 percent of hypothermia patients were alert and
considered to have only mild deficits.
"These data suggest that contrary to the established paradigm,
patients with hypothermia achieve substantial neurological
awakening that may start at day three but is not apparent until day
seven and possibly longer," researchers said.
Their finding should be validated in a study with a higher
number of patients, researchers said.
Shaker M. Eid, M.D., assistant professor of medicine, Johns
Hopkins University School of Medicine, Baltimore, Md.; (410)
900-0495;
seid1@jhmi.edu or
shakeslb@yahoo.com.
(Note: Actual presentation time is 5:15 p.m. CT, Saturday, Nov.
13, 2010.)
Abstract 47 - Withdrawal of early care may prematurely end
life of cardiac arrest patients
Arbitrary withdrawal of life support 72 hours after re-warming
"may prematurely terminate life in at least 10 percent of all
potentially neurologically intact survivors" of cardiac arrest
treated with therapeutic hypothermia, according to a retrospective
study.
Researchers examined the time interval from when patients had
been fully re-warmed to 37 degrees Celsius (98.6 degrees
Fahrenheit) to when they showed definitive signs of awakening
— including being alert and oriented to a person, place or
time.
Comatose patients were generally treated after therapeutic
hypothermia for at least 48 hours before any decision to withdraw
supportive care was made.
The study included 66 patients (average age 59). The time from
9-1-1 call to advanced life support was 9.1 minutes. Six patients
who showed signs of awakening more than 72 hours later had good
neurological function within 30 days of cardiac arrest.
Keith Lurie, M.D., professor of medicine, University of
Minnesota, Minneapolis, Minn.; (612) 986-3917;
klurie@advancedcirculatory.com.
(Note: Actual presentation time is 5:15 p.m. CT, Saturday, Nov.
13, 2010.)
Abstract 232 - Hospitals withdraw care of hypothermia-treated
cardiac arrest patients early
Withdrawing care before 72 hours is common even when specific
protocols to prevent early withdrawal are in place, according to a
multi-center study.
Assessing withdrawal of care for post-cardiac arrest therapeutic
hypothermia patients, researchers examined data from a prospective
study of 1,292 patients with out-of-hospital cardiac arrest treated
in one of 26 state-recognized cardiac receiving centers. All
cardiac receiving centers have protocols with a moratorium on
withdrawal of care at least 72 hours after therapeutic
hypothermia.
Fifty-four percent of patients were excluded because they died
in the emergency department. Of the 177 patients admitted to an ICU
and cooled, care was withdrawn on 59 (33.3 percent) within 24
hours, 53 (29.9 percent) between 25-72 hours and 45 (25.4 percent)
after 72 hours.
Withdrawal of care is highly variable and more emphasis on
continuing care in post- therapeutic hypothermia patients is
warranted, researchers said.
Kyle McCarty, M.D., emergency medicine resident, Maricopa
Medical Center, Phoenix, Ariz.; (602) 344-5011;
Kyle.Mccarty@mihs.org.
(Note: Actual presentation time is 8 a.m. CT, Sunday, Nov. 14,
2010.)
Abstract 1 - Trial finds weak link between epinephrine use,
survival-to-hospital discharge in cardiac arrest cases
Administering epinephrine (adrenaline) in cardiac arrest helped
more patients achieve return of spontaneous circulation (ROSC)
— but didn't necessarily lead to survival-to-hospital
discharge, researchers said.
In a double-blind randomized placebo-controlled study,
researchers randomized out-of-hospital cardiac arrest patients to
receive either saline or epinephrine. They then analyzed survival
to discharge and a return of spontaneous circulation.
Of 535 patients in the study, 262 (48.9 percent) received saline
and 273 (51 percent) received epinephrine. The percentage who
received bystander CPR was similar in both groups. ROSC was
achieved in 83 patients (30.4 percent) receiving epinephrine and 29
patients (11.1 percent) receiving the placebo. Survival to
discharge occurred in 11 patients receiving epinephrine (4.1
percent) and five placebo patients (1.9 percent).
The study's results didn't rule out a clinically meaningful
benefit of epinephrine for survival to hospital discharge; so
researchers said further investigation is warranted.
Ian Jacobs, Ph.D., R.N., professor of resuscitation and
pre-hospital care, University of Western Australia, Nedlands,
Australia; (011) 61-4-1891-6261;
ian.jacobs@uwa.edu.au.
(Note: Actual presentation time is 8:30 a.m. CT, Saturday, Nov.
13, 2010.)
Abstract 51 - AHA guidelines, systems-based approach boost
survival rates for out-of-hospital cardiac arrest
Treating people who suffered cardiac arrest outside a hospital
with a systems-based approach, compared to historical controls,
quadrupled survival rates in a mid-size community, researchers
said.
Beginning in 2006, the EMS system in Colonie, N.Y. (population
80,000) began phasing in recommended therapies from the 2005
American Heart Association's CPR guidelines including:
- 2006 - New CPR guidelines and expanded training using the AHA's
CPR Anytime
- 2007- Use of impedance threshold device and more rapid
deployment of mechanical CPR devices
- 2008 - Improvements in reducing emergency response times,
performing two minutes of CPR prior to defibrillation, and delaying
advanced airway placement and IV access in favor of a period of
high quality CPR
- 2009 - Hospital-based therapeutic hypothermia for comatose
resuscitated arrest patients
Since 2005, about 200 people annually have been trained in CPR;
dispatch improvements reduced response times by one minute; and
three level one cardiac arrest centers were opened. Survival
following out-of-hospital cardiac arrest improved from 4 percent in
2005 (3/75 patients) to 22 percent (14/64 patients) in 2009. The 14
survivors from 2009 were neurologically intact, researchers
said.
Michael Dailey, M.D., FACEP, associate professor of emergency
medicine, Albany Medical College and medical director, Town of
Colonie EMS, Albany, N.Y.; (518) 488-8824;
mwd101@gmail.com.
(Note: Actual presentation time is 5:15 p.m. CT, Saturday, Nov.
13, 2010.)
Author disclosures are available on the abstracts.
SOURCE