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1We conducted a similar review from our single centre district general hospital (DGH) intensive care unit (ICU) for a shorter period of one year. We identified patients retrospectively using ICNARC data and collected 31 items of data per patient from case notes. Our dataset included basic demographics, cardiac arrest details, TH details and outcome up to hospital discharge. The main purpose of our review was to ascertain if our recently introduced trust TH guideline was being appropriately used and efficiently applied. Our numbers (n=21) are interestingly large for a single centre compared with Nichani’s review (102 patients for 9 centres over 15 months). With regard to the application of TH, our trust TH protocol had strict exclusion criteria (no specific contraindications were described in the Nichani review). However, two patients in our review who did not receive TH were inappropriately excluded. The median time to initiate cooling was over 30 minutes faster in our review (95 minutes compared with 126 minutes). Our trust protocol specified that the target temperature of 32-34°C should be reached within two hours of return of spontaneous circulation (ROSC) (no time target was specified in the Nichani review). However, none of the patients in our review reached the target temperature within two hours. In the Nichani review, the median time to 32-34°C was over seven hours (425 minutes). We noted that Nichani was unable to show statistical difference between differing cooling methods. Our review, although not tested to statistical significance, suggested a trend towards better achievement of temperature targets with cold IV fluid infusion. We did not measure total duration of cooling and time to rewarming, but we did measure compliance with the temperature- and time-specific targets for maintenance and rewarming in our protocol. Our results were mixed, showing that 42% of our patients achieved compliance with maintaining temperatures, but only 16% achieved compliance with rewarming temperatures. With regard to outcome for TH, survival to ICU discharge was worse in our unit, at 37%, compared with 45% in the Nichani review. We were also unable to show an improvement in these figures by looking at only VF/VT arrests, with survival of 36% compared with 53% reported by Nichani et al. The patients in our review might have been expected to have more favourable outcomes, as 76% of our patients presented in VF (compared with 68% in the review). However, other factors may have contributed to poorer outcomes – only 57% of our patients received immediate bystander CPR, compared with 80% in the Nichani review; the median age of our patients was 68 years compared to 61 years in the Nichani review, and the median duration of arrest was 23 minutes in our review, compared with 20 minutes in the Nichani review. After completing our review, and in the light of our unit’s level of compliance with regard to achieving the temperatures specified in the TH protocol and poor outcomes in comparison with the Nichani and other reviews, we are embarking upon an educational programme and seeking to purchase a gel pad cooling device to ensure that TH is achieved quickly, adequately maintained and patients rewarmed without rebound hyperthermia. References |
