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deficit between these two methods . Statistically there were significantly more patients out of temperature range while maintaining therapy in the surface cooling group , and an increase in median time spent outside targeted temperature as well . This work further supported earlier studies 22 that advocated the use of either surface pads or intravascular devices for the induction of hypothermia but strongly recommended intravascular devices for maintaining target temperature .
The National Institute for Health and Care Excellence updated its advice on TTM in July 2017 to advocate the use of Arctic Sun over conventional or intravascular cooling methods , due to a combination of reduced risks associated and the potential for improved outcomes .
Conclusions TTM is an extensively researched , effective , neuroprotective strategy with well established guidelines ; however , confusion exists about the optimal duration and target temperature . At the time of writing , the most up-to date research would advocate starting TTM as soon as feasibly possible , but not setting low temperatures ( that is , 33 ° C ) and simply avoiding temperatures above 36 ° C . 17 This obviously remains at the clinician ’ s discretion and temperatures between 35 and 36 ° C are commonplace .
While new devices and research into this treatment are evolving and being undertaken , it is important to reflect on the fundamentals . First , patient selection remains an often-overlooked area , and the authors urge vigilance in selecting those patients who are suitable for instigation of TTM and screening carefully for those likely to benefit from this therapy . To this point , if there is doubt regarding the initial rhythm of arrest , then TTM should be instigated and not withheld .
The clinician involved in the decision to commence TTM must pay attention to the precise control of temperature in all phases , and critically in the rewarming phase where a passive , non-controlled rise could have serious effects on outcome .
Finally , as with most evolving medical research , there is more work to be done , particularly now that 36 ° C temperatures are associated with equal outcomes to 33 ° C . Are we ready to accept normothermia and adopt cooling measures when we see a trend to hyperthermia ?
References 1 London Ambulance Service Cardiac Arrest Annual Report 2012 / 2013 . www . londonambulance . nhs . uk . 2 Berdowski J et al . Global incidences of out-of-hospital cardiac arrest and survival rates : Systematic review of 67 prospective studies . Resuscitation 2010 ; 81 ( 11 ): 1479 – 87 . 3 Perkins GD , Brace-McDonnell SJ . The UK Out of Hospital Cardiac Arrest Outcome ( OHCAO ) project . BMJ Open 2015 ; 5 ( 10 ): e008736 . 4 Bernard SA et al . Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia . N Engl J Med 2002 ; 346 ( 8 ): 557 – 63 . 5 The Hypothermia after Cardiac Arrest Study Group . Mild therapeutic hypothermia to
improve the neurologic outcome after cardiac arrest . N Engl J Med 2002 ; 346 ( 8 ): 549 – 56 . 6 Monsieurs KG et al . European Resuscitation Council Guidelines for Resuscitation 2015 : Section 1 . Executive summary . Resuscitation 2015 ; 95:1 – 80 . 7 Gajić V . [ Forgotten great men of medicine – Baron Dominique Jean Larrey ( 1766-1842 )]. Med Pregl 2011 ; 64 ( 1 – 2 ): 97 – 100 . 8 Benson DW et al . The use of hypothermia after cardiac arrest . Anesth Analg 1959 ; 38:423 – 8 . 9 Williams GR , Spencer FC . The clinical use of hypothermia following cardiac arrest . Ann Surg 1958 ; 148 ( 3 ): 462 – 8 . 10 Knot J , Moťovská Z . Therapeutic hypothermia after cardiac arrest – Part 1 : Mechanism of action , techniques of cooling , and adverse events . Cor et Vasa 2012 ; 54 ( 4 ): e237 – 42 .
11 Steen PA et al . Hypothermia and barbiturates : individual and combined effects on canine cerebral oxygen consumption . Anesthesiology 1983 ; 58 ( 6 ): 527 – 32 . 12 Globus MY-T et al . Detection of free radical activity during transient global ischemia and recirculation : Effects of intraischemic brain temperature modulation . J Neurochem 1995 ; 65 ( 3 ): 1250 – 6 . 13 Zeiner A et al . Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome . Arch Int Med 2001 ; 161 ( 16 ): 2007 – 12 . 14 Soleimanpour H et al . Main complications of mild induced hypothermia after cardiac arrest : A review article . J Cardiovasc Thorac Res . 2014 ; 6 ( 1 ): 1 – 8 . 15 Vaity C , Al-Subaie N , Cecconi M . Cooling techniques
for targeted temperature management post-cardiac arrest . Crit Care [ Internet ]. 2015 [ cited 2017 Nov 21 ]; 19 ( 1 ). www . ncbi . nlm . nih . gov / pmc / articles / PMC4361155 / ( accessed July 2018 ). 16 Diao M et al . Prehospital therapeutic hypothermia after cardiac arrest : A systematic review and meta-analysis of randomized controlled trials . Resuscitation 2013 ; 84 ( 8 ): 1021 – 8 . 17 Nielsen N et al . Targeted temperature management at 33 ° C versus 36 ° C after cardiac arrest . N Engl J Med 2013 ; 369 ( 23 ): 2197 – 206 . 18 Larsson I-M , Wallin E , Rubertsson S . Cold saline infusion and ice packs alone are effective in inducing and maintaining therapeutic hypothermia after cardiac arrest . Resuscitation 2010 ; 81 ( 1 ): 15 – 19 .
19 Mayer SA et al . Clinical trial of a novel surface cooling system for fever control in neurocritical care patients . Crit Care Med 2004 ; 32 ( 12 ): 2508 – 15 . 20 Lyden PD et al . Intravascular cooling in the treatment of stroke ( ICTuS ): early clinical experience . J Stroke Cerebrovasc Dis 2005 ; 14 ( 3 ): 107 – 14 . 21 Glover GW et al . Intravascular versus surface cooling for targeted temperature management after out-ofhospital cardiac arrest - an analysis of the TTM trial data . Crit Care 2016 ; 20 ( 1 ): 381 . 22 Hoedemaekers CW et al . Comparison of cooling methods to induce and maintain normoand hypothermia in intensive care unit patients : a prospective intervention study . Crit Care 2007 ; 11 ( 4 ): R91 .
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