Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets,Intensive Care Medicine

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Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets
Intensive Care Medicine ( IF 38.9 ) Pub Date : 2021-08-13 , DOI: 10.1007/s00134-021-06505-z
Shannon M Fernando _{1,

2} , Pietro Di Santo _{3,

4} , Behnam Sadeghirad _{5,

6} , Jean-Baptiste Lascarrou ₇ , Bram Rochwerg _{6,

8} , Rebecca Mathew _{1,

3} , Mypinder S Sekhon ₉ , Laveena Munshi _{10,

11,

12} , Eddy Fan _{10,

11,

12,

13} , Daniel Brodie _{14,

15} , Kathryn M Rowan ₁₆ , Catherine L Hough ₁₇ , Shelley L McLeod _{6,

18,

19} , Christian Vaillancourt _{2,

4,

20} , Sheldon Cheskes _{19,

21} , Niall D Ferguson _{10,

11,

12,

13} , Damon C Scales _{10,

11,

21,

22} , Claudio Sandroni _{23,

24} , Jerry P Nolan _{25,

26} , Benjamin Hibbert _{3,

4}

Affiliation

Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
Service de Médecine Intensive Reanimation, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes Cedex, France.
Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
Intensive Care National Audit and Research Centre, Napier House, London, UK.
Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA.
Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada.
Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy.
Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.
Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK.
Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.

Purpose

Targeted temperature management (TTM) may improve survival and functional outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA), though the optimal target temperature remains unknown. We conducted a systematic review and network meta-analysis to investigate the efficacy and safety of deep hypothermia (31–32 °C), moderate hypothermia (33–34 °C), mild hypothermia (35–36 °C), and normothermia (37–37.8 °C) during TTM.

Methods

We searched six databases from inception to June 2021 for randomized controlled trials (RCTs) evaluating TTM in comatose OHCA survivors. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was survival with good functional outcome. We used GRADE to rate our certainty in estimates.

Results

We included 10 RCTs (4218 patients). Compared with normothermia, deep hypothermia (odds ratio [OR] 1.30, 95% confidence interval [CI] 0.73–2.30), moderate hypothermia (OR 1.34, 95% CI 0.92–1.94) and mild hypothermia (OR 1.44, 95% CI 0.74–2.80) may have no effect on survival with good functional outcome (all low certainty). Deep hypothermia may not improve survival with good functional outcome, as compared to moderate hypothermia (OR 0.97, 95% CI 0.61–1.54, low certainty). Moderate hypothermia (OR 1.23, 95% CI 0.86–1.77) and deep hypothermia (OR 1.27, 95% CI 0.70–2.32) may have no effect on survival, as compared to normothermia. Finally, incidence of arrhythmia was higher with moderate hypothermia (OR 1.45, 95% CI 1.08–1.94) and deep hypothermia (OR 3.58, 95% CI 1.77–7.26), compared to normothermia (both high certainty).

Conclusions

Mild, moderate, or deep hypothermia may not improve survival or functional outcome after OHCA, as compared to normothermia. Moderate and deep hypothermia were associated with higher incidence of arrhythmia. Routine use of moderate or deep hypothermia in comatose survivors of OHCA may potentially be associated with more harm than benefit.

中文翻译：

院外心脏骤停后的目标温度管理：温度目标的系统评价和网络荟萃分析

目的

目标温度管理 (TTM) 可以改善院外心脏骤停 (OHCA) 昏迷幸存者的生存率和功能结果，尽管最佳目标温度仍然未知。我们进行了系统回顾和网络荟萃分析，以研究深低温（31-32°C）、中度低温（33-34°C）、轻度低温（35-36°C）和常温的有效性和安全性（ 37–37.8 °C) 在 TTM 期间。

方法

我们搜索了从成立到 2021 年 6 月的六个数据库，以寻找评估昏迷 OHCA 幸存者 TTM 的随机对照试验 (RCT)。两名审稿人独立进行筛选、全文审阅和提取。感兴趣的主要结果是生存和良好的功能结果。我们使用 GRADE 来评估我们的估计确定性。

结果

我们纳入了 10 个 RCT（4218 名患者）。与常温相比，深低温（优势比 [OR] 1.30，95% 置信区间 [CI] 0.73-2.30）、中度低温（OR 1.34，95% CI 0.92-1.94）和轻度低温（OR 1.44，974% CI 0.0.） –2.80) 可能对具有良好功能结果的生存没有影响（所有低确定性）。与中度低温（OR 0.97，95% CI 0.61–1.54，低确定性）相比，深度低温可能不会改善生存并具有良好的功能结果。与常温相比，中度低温 (OR 1.23, 95% CI 0.86–1.77) 和深度低温 (OR 1.27, 95% CI 0.70–2.32) 可能对生存率没有影响。最后，与常温（均为高确定性）相比，中度低温（OR 1.45，95% CI 1.08-1.94）和深度低温（OR 3.58，95% CI 1.77-7.26）的心律失常发生率更高。