Interventional procedure overview of temperature control to improve neurological outcomes after cardiac arrest
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Existing assessments of this procedure
International guidance
International Liaison Committee on Resuscitation (ILCOR): International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations – for adult advanced life support(2022) includes updated recommendations on targeted temperature management after cardiac arrest. This is based on the systematic review on temperature management after cardiac arrest (Granfeldt 2021). These include the following:
Suggest actively preventing fever by targeting a temperature ≤37.5°C for patients who remain comatose after ROSC from cardiac arrest (weak recommendation, low-certainty evidence).
Whether subpopulations of cardiac arrest patients may benefit from targeting hypothermia at 32°C to 34°C remains uncertain.
Comatose patients with mild hypothermia after ROSC should not be actively warmed to achieve normothermia (good practice statement).
Recommend against the routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC (strong recommendation, moderate-certainty evidence). Recommendation unchanged from 2015 because they found no evidence that any method of prehospital cooling improved outcomes.
Suggest surface or endovascular temperature control techniques when temperature control is used in comatose patients after ROSC (weak recommendation, low-certainty evidence).
When a cooling device is used, they suggest using a temperature control device that includes a feedback system based on continuous temperature monitoring to maintain the target temperature (good practice statement).
Suggests active prevention of fever for at least 72 hours in post–cardiac arrest patients who remain comatose (good practice statement).
The Task Force proposes that the following terms be used for clarity in future studies and recommendations:
• Temperature control with hypothermia: Active temperature control with the target temperature below the normal range
• Temperature control with normothermia: Active temperature control with the target temperature in the normal range
• Temperature control with fever prevention: Monitoring temperature and actively preventing and treating temperature above the normal range
• No temperature control: No protocolized active temperature control strategy.
American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (2020) includes the following recommendations for targeted temperature management:
'Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcomes.
Use TTM for adults who do not follow commands after ROSC from OHCA with any initial rhythm.
Use TTM for adults who do not follow commands after ROSC from IHCA with initial non-shockable rhythm.
Use TTM for adults who do not follow commands after ROSC from IHCA with initial shockable rhythm.
TTM between 32°C and 36°C for at least 24 hours is currently recommended for all cardiac rhythms in both OHCA and IHCA.'
European Resuscitation Council (ERC): Guidelines for resuscitation (2021) on temperature control post-resuscitation recommends as follows:
'We recommend targeted temperature management (TTM) for adults after either OHCA or in-hospital cardiac arrest (IHCA) (with any initial rhythm) who remain unresponsive after ROSC.
Maintain a target temperature at a constant value between 32°C and 36°C for at least 24 h.
Avoid fever (> 37.7°C) for at least 72 h after ROSC in patients who remain in coma.
Do not use pre-hospital intravenous cold fluids to initiate hypothermia.'
ERC-ESICM Recommendations for temperature control after cardiac arrest in adults (2022): 'these updated temperature control guidelines are the result of a collaboration between the European Resuscitation Council and the European Society of Intensive Care Medicine and emphasize the importance of active prevention of fever after cardiac arrest.
We recommend continuous monitoring of core temperature in patients who remain comatose after ROSC from cardiac arrest (good practice statement).
We recommend actively preventing fever (defined as a temperature >37.7° C) in post-cardiac arrest patients who remain comatose (weak recommendation, low-certainty evidence).
We recommend actively preventing fever for at least 72 hours in post-cardiac arrest patients who remain comatose (good practice statement).
Temperature control can be achieved by exposing the patient, using anti-pyretic drugs, or if this is insufficient, by using a cooling device with a target temperature of 37.5°C (good practice statement).
There is currently insufficient evidence to recommend for or against temperature control at 32–36°C in sub-populations of cardiac arrest patients or using early cooling, and future research may help elucidate this.
We recommend not actively rewarming comatose patients with mild hypothermia after ROSC to achieve normothermia (good practice statement).
We recommend not using prehospital cooling with rapid infusion of large volumes of cold IV fluid immediately after ROSC (strong recommendation; moderate certainty evidence).'
UK post resuscitation care guidelines (2021) on temperature control recommends that:
'Targeted temperature management (TTM) is recommended for adults after either out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) with any initial rhythm who remain unresponsive after ROSC.
Maintain a target temperature at a constant value between 32°C and 36°C for at least 24 h.
Avoid fever (> 37.7°C) for at least 72 h after ROSC in patients who remain in coma.
Do not use pre-hospital intravenous cold fluids to initiate hypothermia.'
Guidelines from a French expert panel on targeted temperature management in the ICU (2017) makes the following recommendations
TTM after cardiac arrest
1.1 'We recommend using TTM in order to improve survival with good neurological outcome in patients resuscitated from out-of-hospital cardiac arrest (OHCA) with shockable cardiac rhythm (ventricular fbrillation and pulseless ventricular tachycardia) and who remain comatose after return of spontaneous circulation (ROSC).
1.2 We suggest considering TTM in order to improve survival with good neurological outcome in patients resuscitated from OHCA with non-shockable cardiac rhythm (asystole or pulseless electrical activity) and who remain comatose after ROSC.
1.3 We suggest considering TTM in order to increase survival with good neurological outcome in patients resuscitated from in-hospital cardiac arrest (IHCA) who remain comatose after ROSC.
1.4 We suggest considering TTM between 32 and 36 °C in order to improve survival with good neurological outcome after cardiac arrest.
1.5 We do not suggest initiating TTM with infusion of large volumes of cold saline solution during transportation to the hospital after cardiac arrest'.
The Australian and New Zealand Committee on Resuscitation (ANZCOR) guideline (2016) makes the following recommendations:
1. 'ANZCOR recommends TTM as opposed to no TTM for adults with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who remain unresponsive after ROSC.
2. ANZCOR suggests TTM as opposed to no TTM for adults with OHCA with an initial non-shockable rhythm who remain unresponsive after ROSC.
3. ANZCOR suggests TTM as opposed to no TTM for adults with in-hospital cardiac arrest (IHCA) with any initial rhythm who remain unresponsive after ROSC.
4. ANZCOR recommends selecting and maintaining a constant target temperature between 32°C and 36°C for those patients in whom TTM is used.
5. No studies specifically address cardiac arrests due to non-cardiac causes, but it is reasonable to assume that these patients might also benefit from targeted temperature management.
6. Rapid infusion of ice-cold intravenous fluid, up to 30 ml kg-1 or ice packs are feasible, safe and simple methods for initially lowering core temperature up to 1.5 degrees. When intravenous fluids are used to induce hypothermia additional cooling strategies will be required to maintain hypothermia.
7. ANZCOR recommends against routine use of pre-hospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC.
8. ANZCOR suggests that if TTM is used, duration should be at least 24 hours.
9. ANZCOR suggests that percutaneous coronary intervention during TTM is feasible and safe and may be associated with improved outcome.
10. ANZCOR suggests institutions or communities planning to implement complex guidelines, such as targeted temperature management should consider using a comprehensive, multifaceted approach, including: clinical champions; a consensus-building process; multidisciplinary involvement; written protocols; detailed process description; practical logistic support; multi-modality, multi-level education; and rapid cycle improvement methods.
11. ANZCOR suggests prevention and treatment of fever in persistently comatose adults after completion of TTM between 32°C and 36°C.'
Canada's Drug and Health Technology Agency (CADTH) health technology rapid review on temperature management in patients after cardiac arrest (2022) included 2 systematic reviews (1 with a network meta-analysis and 1 with a meta-analysis), 1 RCT, and 7 non-randomised studies, comparing the clinical effectiveness of normothermia against hypothermia in adult patients after cardiac arrest.
The key messages from the review were:
'Normothermia was found to be similar to hypothermia for several clinical- and patient-related outcomes, such as survival, hospital mortality, and quality of life. There was limited evidence to suggest that either type of targeted temperature management was more efficacious, with findings suggesting that normothermia may be associated with greater protocol adherence and decreased prescription medication use coming from low-quality non-randomized studies.
Four evidence-based guidelines were identified regarding targeted temperature management (normothermia or hypothermia) in adult patients after cardiac arrest. All guidelines strongly recommend targeted temperature management for eligible patients, particularly for patients resuscitated following out-of-hospital cardiac arrest. Identified guidelines from the Canadian Cardiovascular Society and American Academy of Neurology present strong recommendations for hypothermic targeted temperature management.'
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