used TH. The study concluded that TH recommendations should be incorporated more formally into resuscitation guidelines and hospital policies to drive improvements in utilization. This is more recently stated as a class I/LOE B recommendation in the 2010 ACLS Guidelines. TH for post CA care following return of spontaneous circulation (ROSC) after ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) patients is of particular importance in those patients with neurological injury. It is furthermore stated with a class IIb/ LOE C recommendation, that TH may be considered as a part of the post CA care for ROSC after asystole/pulseless electrical activity (PEA) patients, when the patient remains comatose. The 2010 ACLS Guidelines distinguish between comatose survivors of CA associated with initial shockable versus non-shockable rhythms. Levels of scientific evidence and graded recommendations for the utilization of TH in the post CA care in these two groups of patients differ. Likewise, the European Resuscitation Council Guidelines for Resuscitation 2010 acknowledges the lower level of evidence for the use of TH after CA from non-shockable rhythms, but nevertheless recommend using TH for both shockable and non-shockable rhythms in comatose cardiac arrest survivors. Recently also the recommendations from five professional critical care societies have been published. In brief, it is the jury opinion, that the term ‘targeted temperature management’ (TTM) replace ‘therapeutic hypothermia’ and that descriptors such as ‘mild’ be replaced with explicit targeted temperature management profiles. Furthermore, it was strongly recommended to use TTM
Of the 11 patients subjected to TTM due to a CA condition, the outcomes were as follows: one OOHCA patient died due to unrecoverable cardiogenic shock, six patients remained in a vegetative condition and four patients (Three OOHCA, one in-hospital CA) were discharged with full neurological recovery. All patients managed with TTM in our institution have had cooling treatment initiated in the critical care areas. We are working towards starting TTM treatment early within the emergency department in order to achieve an earlier neuro-protective effect for OOHCA patients. Furthermore, we are preparing to extend the scope of TTM treatment towards our pediatric patient population according to the current guidelines. To date, we have not experienced any complications associated with TTM and we are satisfied with our preliminary outcome results in this extremely morbid patient population. For every six patients managed with TTM one patient will have improved survival.
CONCLUSION The most effective concept for increasing the survival rate and the neurological outcome after cardiac arrest is currently TTM. The treatment onset should be as early as possible (within at most six hours of ROSC) and the targeted temperature range should be 32-34°C maintained for (12-) 24 hours. From demographic data coming from the US and from Europe, implementing TTM for post CA patients in the UAE can prevent up to 150 patients from suffering an unfavorable neurological outcome every year.
“Many Ca survivors reMain in a vegetative state for the rest of their lives, with Major iMpaCt on life quality for both the patients and relatives”
32 – 34°C as preferred treatment of OOHCA patients with initial rhythm VF or PEA and still unconscious after ROSC. The only non-CA critical care condition currently associated with a recommendation from the representatives of five international critical care societies and from the ERC 2010 Guidelines is in the treatment of term newborns who sustained asphyxia and exhibit acidosis and/or encephalopathy. Numerous other critical care conditions such as myocardial infarction, acute ischemic stroke, traumatic brain and spinal cord injury, fever, acute liver failure and consecutive cerebral edema, and ARDS, etc. have been investigated for possible improved outcomes associated with cooling strategies. However, no published data has so far supported or refuted the utilization of TH in these conditions and consequently, none of these conditions have been associated with a TTM recommendation. The critical care condition, that is currently under major clinical trial investigation for a possible benefit from TTM treatment is traumatic brain injury (TBI) associated with increased intracranial pressures.
IMPLEMENTATION OF TARGETED TEMPERATURE MANAGEMENT – OUR LOCAL EXPERIENCE In 2009, SKMC implemented a standardized TTM protocol for adult post CA patients remaining comatose after ROSC. We simultaneously invested in purpose designed surface cooling devices. TTM nursing and physician training was conducted and the SKMC TTM protocol for adult post CA patients was approved by the hospital P&T committee in October 2010. Since then, 13 patients have been treated with TTM within 6 hours following return of spontaneous circulation (ROSC): 10 patients with OOHCA, one patient with in-hospital CA and two patients with neurologically induced fever.
060 ARAB HEALTH MAGAZINE ISSUE 2 2012
REFERENCES References available on request (
magazine@informa.com)
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