**4. Guidelines**

In 2005, guidelines for resuscitation and emergency cardiac care of the European Resuscitation Council and the American Heart Association recommended that the core body temperature of unconscious adult patients with spontaneous circulation after a VF OHCA should be lowered to 32 to 34°C (Class IIA recommendation).[56] Cooling should be started as soon as possible after the arrest and should be continued for at least 12 to 24 hours.

The guidelines note that patients who have had a cardiac arrest due to nonshockable rhythms and patients who have had a cardiac arrest in the hospital may also benefit from induced hypothermia (Class IIB recommendation).56

With more evidence and trials showing the feasibility and the evidence supporting TH for cardiac arrest patients, the new guidelines by European Resuscitation Council and the American Heart Association in **2010** recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours (**Class I**).[57] Induced hypothermia also may be considered for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of pulseless electrical activity or asystole (**Class IIb**).[57] Active rewarming should be avoided in comatose patients who spontaneously develop a mild degree of hypothermia (32°C [89.6°F]) after resuscitation from cardiac arrest during the first 48 hours after ROSC. (**Class III**).[57]

## **5. Cooling methods**

26 Therapeutic Hypothermia in Brain Injury

can be obtained.

**4. Guidelines** 

hours.

**3.3. Asphyxial causes of cardiac arrest** 

comparing TH with normothermia in patients with an initial cardiac rhythm asystole or PEA would require very large numbers of patients to get enough power to show improved

Suffocation is the second leading cause of death from suicide in the United States, accounting for 22.5% of the 33 300 suicide-related deaths.[49] Victims of near-hanging may carry a poor prognosis even if cardiac arrest has not occurred. Those who suffer cardiac arrest, present with a Glasgow Coma Scale (GCS) of 5 or less, and experience a longer hanging time have the worst prognosis.[50,51]Nearhanging is defined as an unsuccessful attempt at hanging. Victims of near-hanging suffer from strangulation with cerebral ischemia-reperfusion injury rather than a fatal cervical spine injury. Therapeutic Hypothermia has not been prospectively studied in this patient population, and it is doubtful that large randomized, controlled trials comparing TH with normothermia will be conducted. There are few retrospective reviews and case reports and case series on asphyxiated patients with or without cardiac arrests who had good neurologic recovery after therapeutic hypothermia.[52-55] Although it would be difficult to conduct good prospective studies, the compiling case studies, anecdotal evidence, and extrapolated data support the use of therapeutic hypothermia for asphyxial cardiac arrest until more evidence

In 2005, guidelines for resuscitation and emergency cardiac care of the European Resuscitation Council and the American Heart Association recommended that the core body temperature of unconscious adult patients with spontaneous circulation after a VF OHCA should be lowered to 32 to 34°C (Class IIA recommendation).[56] Cooling should be started as soon as possible after the arrest and should be continued for at least 12 to 24

The guidelines note that patients who have had a cardiac arrest due to nonshockable rhythms and patients who have had a cardiac arrest in the hospital may also benefit from

With more evidence and trials showing the feasibility and the evidence supporting TH for cardiac arrest patients, the new guidelines by European Resuscitation Council and the American Heart Association in **2010** recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours (**Class I**).[57] Induced hypothermia also may be considered for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of pulseless electrical activity or asystole (**Class IIb**).[57] Active rewarming should be avoided in comatose patients who spontaneously develop a mild degree of

induced hypothermia (Class IIB recommendation).56

outcomes, and thus is unlikely that such trials will be conducted.

#### **5.1. Methods for induction of therapeutic hypothermia**

Bernard et al., reported the results of a clinical trial of the rapid infusion of large-volume (30 ml/kg), ice-cold (4°C) lactated ringer's solution in comatose survivors of OHCA. This study found that this approach decreased core temperature by 1.6°C over 25 minutes with no adverse events.[58] Polderman, et al., used in addition to surface cooling, 30ml/kg (mean 2.3 liters) of cold normal saline over 50 minutes that showed similar results.[59] Several small randomized trials, and nonrandomized observational and retrospective trials, looked at prehospital cooling initiation for patients with OHCA with large-volume ice-cold (4°C) fluids (discussed in more detail in a separate chapter: **Prehospital Therapeutic Hypothermia for Cardiac Arrest).[**60-68] All these studies documented the safety and feasibility if ice-cold fluids for the rapid induction of therapeutic hypothermia. Other promising methods for induction of hypothermia include transnasal cooling device [69], self-adhesive cooling pads [70], and cranial cooling caps.[71]

#### **5.2. Methods for maintenance of therapeutic hypothermia**

An ideal cooling method would be one that will help with rapid induction of cooling, costeffective, easily implemented, safe, effective, and able to maintain the temperature with minimal variations.

#### *5.2.1. Surface cooling*

Ice packs are still used in some centers for induction and maintenance of hypothermia, by applying them to the head, neck, torso and extremities. Disadvantages of this method include slow cooling rate, labor-intensive for the nurses, and wide fluctuations with overshooting and undercooling or unintentional rewarming.[40,72,73]

An effective surface cooling system uses cooling blanket (Arctic Sun, Medivance, Louisville, CO, USA). This technology can cool as fast as 1.2°C per hour through especially designed pads, is radiolucent (can be used during cardiac catheterization), has minimal temperature variation (operates with feedback control), and can perform active controlled rewarming. The pads can be applied easily by the nurses. Disadvantages include expense, possible skin sloughing, and slower cooling rates in very obese people.[72,74]

A promising technology is the Thermosuit System (Life Recovery Systems, Kinnelon, NJ, USA), which surrounds patients directly with cool water and also possesses a feedback control mechanism. Animal studies suggest that it provides a cooling rate of 9.7°C per hour in 30-kg pigs, versus 3.0°C per hour in humans. Disadvantages include expense and hindering appropriate physical exams.[75,76]

#### *5.2.2. Intravascular cooling*

The CoolGard System (Alsius, Irvine, CA, USA) is one of the products that uses Intravascular devices. This technology works by exchanging heat through a catheter containing circulating saline at a controlled temperature with a feedback of patient temperature. This technology can cool as fast as 1 to 1.5 °C per hour, is very good at maintaining goal temperature (feedback mechanism) and cal also provide active controlled rewarming. Disadvantages are those of central venous catheters (risks of bleeding, vessel thrombosis, and catheter-related infection). It also requires placement by a physician, which if not readily available, may delay initiation of this important and timely therapy.[77.78]

Therapeutic Hypothermia for Cardiac Arrest 29

[1] Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group (2004) Advanced cardiac life

[2] Keenan SP, Dodek P, Martin C, Priestap F, Norena M, Wong H (2007) Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as

[3] Mashiko K, Otsuka T, Shimazaki S, Kohama A, Kamishima G, Katsurada K, Sawada Y, Matsubara I, Yamaguchi K (2002) An outcome study of out-of-hospital cardiac arrest

[4] Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K (2007) Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis

[5] Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA (2003) In-hospital factors associated with improved outcome after out-ofhospital cardiac arrest: a

[6] Herlitz J, Engdahl J, Svensson L, Angquist KA, Silfverstolpe J, Holmberg S (2006) Major differences in 1-month survival between hospitals in Sweden among initial survivors of

[7] Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT Jr, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T (2008) Post– cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 118:2452–2483. [8] Eisenberg MS, Mengert TJ (2001) Cardiac Resuscitation. N Engl J Med 334: 1304-1313. [9] Bunch TJ, White RD, Smith GE, Hodge DO, Gersh BJ, Hammill SC, Shen WK, Packer DL (1998) Long-term subjective memory function in ventricular fibrillation out-ofhospital cardiac arrest survivors resuscitated by early defibrillation. Resuscitation

[10] Laver S, Farrow C, Turner D, Nolan J (2004) Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 30:2126 –2128. [11] Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, Cassan P, Coovadia A, D'Este K, Finn J, Halperin H, Handley A, Herlitz J, Hickey R, Idris A, Kloeck W, Larkin GL,

using the Utstein template: a Japanese experience. Resuscitation 55:241–246.

of the ICNARC Case Mix Programme Database. Anaesthesia 62:1207–1216.

comparison between four regions in Norway. Resuscitation 56:247–263.

out-of-hospital cardiac arrest. Resuscitation 70:404–409.

support in out-of-hospital cardiac arrest. N Engl J Med 351:647– 656.

who you are. Crit Care Med 35: 836–841.

**7. References** 

36:111-122.

Although many devices are available to achieve and maintain therapeutic hypothermia, there are no current data recommending one method over another, or comparing them against each other. Several factors need to be taken into consideration, such as patient factors, nursing factors and nurse to patient ratios, and institutional factors when making a decision regarding the optimal method.

#### **6. Conclusion**

On the basis of current evidence, comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours, as fast as possible. Therapeutic Hypothermia should be strongly considered for other rhythms, for inhospital arrests, and for cardiac arrest secondary to asphyxia. Intensivists should be familiar with techniques to induce, maintain, and rewarm from therapeutic hypothermia, and select the most appropriate method for a given patient, and institution. Research questions for the future are whether very early cooling, or longer cooling periods (eg, 72 h), or both can further improve outcome.

#### **Author details**

Farid Sadaka *Mercy Hospital St Louis/St Louis University ,Critical Care Medicine/Neurocritical Care, St Louis* 

## **Acknowledgement**

No additional acknowledgements.

#### **Conflicts of interest**

The author reports no conflicts of interest. The author declares that no competing financial interests exist. The author reports that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

#### **7. References**

28 Therapeutic Hypothermia in Brain Injury

*5.2.2. Intravascular cooling* 

decision regarding the optimal method.

**6. Conclusion** 

improve outcome.

**Author details** 

**Acknowledgement** 

**Conflicts of interest** 

No additional acknowledgements.

The author reports no conflicts of interest.

The author declares that no competing financial interests exist.

whose products or services may be discussed in this article.

Farid Sadaka

The CoolGard System (Alsius, Irvine, CA, USA) is one of the products that uses Intravascular devices. This technology works by exchanging heat through a catheter containing circulating saline at a controlled temperature with a feedback of patient temperature. This technology can cool as fast as 1 to 1.5 °C per hour, is very good at maintaining goal temperature (feedback mechanism) and cal also provide active controlled rewarming. Disadvantages are those of central venous catheters (risks of bleeding, vessel thrombosis, and catheter-related infection). It also requires placement by a physician, which

if not readily available, may delay initiation of this important and timely therapy.[77.78]

Although many devices are available to achieve and maintain therapeutic hypothermia, there are no current data recommending one method over another, or comparing them against each other. Several factors need to be taken into consideration, such as patient factors, nursing factors and nurse to patient ratios, and institutional factors when making a

On the basis of current evidence, comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours, as fast as possible. Therapeutic Hypothermia should be strongly considered for other rhythms, for inhospital arrests, and for cardiac arrest secondary to asphyxia. Intensivists should be familiar with techniques to induce, maintain, and rewarm from therapeutic hypothermia, and select the most appropriate method for a given patient, and institution. Research questions for the future are whether very early cooling, or longer cooling periods (eg, 72 h), or both can further

*Mercy Hospital St Louis/St Louis University ,Critical Care Medicine/Neurocritical Care, St Louis* 

The author reports that no potential conflicts of interest exist with any companies/organizations


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**Chapter 3** 

© 2013 Sadaka, licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 Sadaka, licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In the era before Therapeutic Hypothermia (TH) was recommended and used as a therapeutic modality for out-of-hospital cardiac arrest (OHCA) patients, reported data suggests in-hospital mortality exceeded 58%.[1,2,3,4,5,6] Mortality after a sudden and unexpected cardiac arrest (CA) is high, and the chance of survival to hospital discharge has, until recently, remained unchanged.[7] In one report, OHCA in the U.S. has a mortality rate greater than 90% which results in more than 300,000 deaths per year.[8] Those who survive the devastating event, often retain a hypoxic brain injury and a permanently incapacitating neurologic deficit.[9] Studies of patients who survived to ICU admission but subsequently died in the hospital, brain injury was the cause of death in 68% after out-of-hospital cardiac

Recent studies have indicated that TH with a reduction of body core temperature (T) to 33 °C over 12 to 24 hours has improved survival and neurologic outcome in OHCA patients. In 2002, the European Hypothermia after Cardiac Arrest Study Group demonstrated an improvement in survival from witnessed V-fib cardiac arrest from 41% to 55% and an improvement in favorable neurologic outcome among survivors from 39% to 55% when TH of 32-34°C was maintained for the first 24 hours post cardiac arrest.[12] Bernard demonstrated similar neurologic outcome benefits from 12 hours of TH at 32-34°C induced on the same patient population in Australia.[13] Recently, a meta-analysis showed that therapeutic hypothermia is associated with a risk ratio of 1.68 (95% CI,1.29-2.07) favoring a good neurologic outcome when compared with normothermia. The meta-analysis concluded the number needed to treat (NNT) to produce one favorable neurological recovery was 6.[14] This would translate to improved neurological recovery in > 10,000 patients per year in the U.S.[14] Also, recent evidence has now shown that the treatment is

**Prehospital Therapeutic** 

Additional information is available at the end of the chapter

arrest and in 23% after in-hospital cardiac arrest.[10,11]

beneficial in cases with non-VF initial rhythm.[15,16,17,18,19].

Farid Sadaka

http://dx.doi.org/10.5772/49049

**1. Introduction** 

**Hypothermia for Cardiac Arrest** 


#### **Chapter 3**
