Episode 17 - New evidence: physician perspectives on post-arrest neuroprognostication

A new multicenter trial published in NEJM, commonly known as the “TTM2” trial, evaluated treating patients resuscitated from out-of-hospital cardiac arrest with targeted temperature management to 33C versus controlled normothermia, and found that outcomes were equivalent.  Does this mean the end of TTM as we know it?  In this podcast, Dr. Benjamin Abella presents a comprehensive argument why he believes that such pronouncements are premature and not consistent with the larger body of laboratory and clinical science over the past 20 years. He discusses TTM2 in context of recent work from France (the Hyperion study), as well as work from the US and Japan, suggesting that patient selection is key.  TTM may not be needed for patients with favorable characteristics (witnessed arrest, bystander CPR, no evidence of shock) but still may be required for patients with less favorable characteristics (non-shockable arrest rhythms, no bystander CPR, evidence of shock).   Also join us for a free live Zoom webinar on June 24 at 4 PM EDT US time to discuss the TTM2 trial. Registration at: https://pennmedicine.zoom.us/webinar/register/WN_JrHlS0lFRreZ6Otzr4LcnA   Key references: Dankiewicz J, Cronberg T, Lilja G,  et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021 Jun 17;384(24):2283-2294. https://pubmed.ncbi.nlm.nih.gov/34133859/  Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019 Dec 12;381(24):2327-2337.  https://pubmed.ncbi.nlm.nih.gov/31577396/  Callaway CW, Coppler PJ, Faro J, et al. Association of Initial Illness Severity and Outcomes After Cardiac Arrest With Targeted Temperature Management at 36 °C or 33 °C. JAMA Netw Open. 2020 Jul 1;3(7):e208215. https://pubmed.ncbi.nlm.nih.gov/32701158/  Nishikimi M, Ogura T, Nishida K, et al. Outcome Related to Level of Targeted Temperature Management in Postcardiac Arrest Syndrome of Low, Moderate, and High Severities: A Nationwide Multicenter Prospective Registry. Crit Care Med. 2021 Apr 8. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/33826582/ 

Electrocardiography (ECG) represents a central diagnostic tool in the post-arrest evaluation of patients resuscitated from out-of-hospital cardiac arrest (OHCA), and it should be acquired immediately after achievement of ROSC to identify the need for an urgent coronary angiography, which is indicated only in the case of ST-segment elevation myocardial infarction (STEMI). While resuscitation guidelines are clear in the recommendation and importance of obtaining an ECG during the post-ROSC phase, they don’t provide specific instructions about the best time for ECG acquisition after ROSC.   In this context some have proposed that the timing of ECG post-ROSC may have an impact in the early post-ROSC phase, and that the ECG could reflect ischemia secondary to cardiac arrest more than or in addition to ischemia due to coronary artery pathology, possibly leading to overdiagnosis of STEMI.   In episode 24 of the TTM Academy Podcast we review a recent study published in JAMA Network Open, by authors Enrico Baldi, Simone Savatano and colleagues, who performed a retrospective, multicenter cohort study evaluating whether the time from ROSC to ECG acquisition is associated with the percentage of false-positive ECG findings for STEMI in patients resuscitated from OHCA.   Citation of the study and accompanying Editorial commentary: Baldi E, Schnaubelt S, Caputo ML, et al. Association of Timing of Electrocardiogram Acquisition After Return of Spontaneous Circulation With Coronary Angiography Findings in Patients With Out-of-Hospital Cardiac Arrest JAMA Netw Open. 2021; 4(1):e2032875-. DOI: 10.1001/jamanetworkopen.2020.32875 Kalra R, Yannopoulos D. Delaying Electrocardiography in Cardiac Arrest: A Pause for the Cause JAMA Netw Open. 2021; 4(1):e2033360-. DOI: 10.1001/jamanetworkopen.2020.33360 

While we have focused on the science of targeted temperature management and other care strategies for critically ill survivors, it is important for us to remember that real people experience cardiac arrest and the consequences. In this unique episode, Dr. Benjamin Abella interviews Kristin Flanary, who jumped into action to provide 10 minutes of bystander CPR to her husband, Dr. Will Flanary, who has thankfully made a full recovery. You may know Kristin and Will as @lglaucomflecken and @dglaucomflecken , well-known on twitter – we are grateful that Kristin has chosen to go public with her story and support advocacy for cardiac arrest and post-arrest care.   Suggested readings on bystander CPR and survivorship: Brian Anderson. The Conversation That Can Change the Course of a Cardiac Arrest. The Atlantic, 2021.   https://www.theatlantic.com/health/archive/2021/02/tcpr-telephone-cpr-can-save-lives/618145/ Riva G, et al. Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardiac arrest.  Resuscitation, 2020 Dec;157:195-201. doi: 10.1016/j.resuscitation.2020.08.125.  https://pubmed.ncbi.nlm.nih.gov/32918983/ Sawyer et al, Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation. 2020 Mar 24;141(12):e654-e685. https://pubmed.ncbi.nlm.nih.gov/32078390/

The role of oxygenation during critical illness remains a major question.  Is extra oxygen harmful or helpful? What oxygen levels should we target, both for respiratory failure and for patients after cardiac arrest? Dr. Benjamin Abella discusses these topics, and reviews a hot-of-the-press work from European investigators (the “HOT-ICU”) trial, published in New England Journal of Medicine this month. The paper evaluates two different oxygen targets for patients with respiratory failure – implications for this work as it pertains to cardiac arrest will be discussed.   Key publications: Schjørring OL, Klitgaard TL, Perner A et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. NEJM 2021; Jan 20. doi: 10.1056/NEJMoa2032510. Roberts BW, Kilgannon JH, Hunter BR, et al. Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study. Circulation. 2018 May 15;137(20):2114-2124. Kilgannon JH, Jones AE, Shapiro NI, Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010 Jun 2;303(21):2165-71.

Critical illness from COVID19 remains a major challenge to health systems worldwide. When patients progress to in-hospital cardiac arrest (IHCA), what is the chance of survival?  Studies have so far revealing conflicting answers to this important question.  What is the role of post-arrest care bundles, including TTM, in the care process?  Dr. Felipe Teran will lead a conversation with Dr. Oscar Mitchell, who served as the lead author in a new multicenter study of COVID19 IHCA survival, to be presented as a late-breaking abstract at the Resuscitation Science Symposium.   Key publications: Girotra S, Tang Y, Chan PS, Nallamothu BK; American Heart Association Get With The Guidelines–Resuscitation Investigators. Survival After In-Hospital Cardiac Arrest in Critically Ill Patients: Implications for COVID-19 Outbreak? Circ Cardiovasc Qual Outcomes. 2020 Jul;13(7):e006837.   Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19. JAMA Intern Med. 2020 Sep 28:e204796. Hayek SS, Brenner SK, Azam TU, Shadid HR, Anderson E, Berlin H, Pan M, Meloche C, Feroz R, O'Hayer P, Kaakati R, Bitar A, Padalia K, Perry D, Blakely P, Gupta S, Shaefi S, Srivastava A, Charytan DM, Bansal A, Mallappallil M, Melamed ML, Shehata AM, Sunderram J, Mathews KS, Sutherland AK, Nallamothu BK, Leaf DE; STOP-COVID Investigators. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ. 2020 Sep 30;371:m3513. Sheth V, Chishti I, Rothman A, Redlener M, Liang J, Pan D, Mathew J. Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City. Resuscitation. 2020 Oct;155:3-5. Shao F, Xu S, Ma X, Xu Z, Lyu J, Ng M, Cui H, Yu C, Zhang Q, Sun P, Tang Z. In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation. 2020 Jun;151:18-23.

Dr. Felipe Teran joins Drs. Cindy Hsu and Hans van Schuppen to discuss recent guidance regarding cardiac arrest resuscitation during the COVID-19 pandemic. Key publications referenced in this episode:  Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020; 151:59-66. https://pubmed.ncbi.nlm.nih.gov/32325096/ Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation. 2020 https://pubmed.ncbi.nlm.nih.gov/32270695/ Perkins GD, Morley PT, Nolan JP, et al. International Liaison Committee on Resuscitation: COVID-19 consensus on science, treatment recommendations and task force insights. Resuscitation. 2020; 151:145-147. https://pubmed.ncbi.nlm.nih.gov/32371027/ Perkins GD, Couper K. COVID-19: long-term effects on the community response to cardiac arrest? Lancet Public Health. 2020 https://pubmed.ncbi.nlm.nih.gov/32473112/

Dr. Felipe Teran discusses the recent studies pertainig to OHCA during the COVID-19 pandemic.   Key publications referenced in this episode: Baldi E et al. Out-of-hospital cardiac arrest during the Covid-19 outbreak in Italy. N Engl J Med 2020 Apr 29; [e-pub]. (https://doi.org/10.1056/NEJMc2010418) Marijon E, Karam N, Jost D, et al. Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. Lancet Public Health. 2020 Sayre MR, Barnard LM, Counts CR, et al. Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR. Circulation. 2020. DOI: 10.1161/CIRCULATIONAHA.120.048951

Dr. Abella discusses a very recent American Heart Association scientific statement on cardiac arrest survivorship, increasingly recognized as an important topic around the globe. While many studies have evaluated survival to hospital discharge, or even survival at 90 or 180 days post-arrest – survival is not enough. Increasing data suggest that even among “good” neurologic survivors (those with Cerebral Performance Category 1 or 2), life-limited challenges remain, including depression, PTSD, cognitive deficits and other challenges to quality of life.   Key readings:  Sawyer KN, et al. Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation 2020 Feb 12 [epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/32078390   Lilja G, et al. Return to Work and Participation in Society After Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2018 Jan;11(1):e003566. https://www.ncbi.nlm.nih.gov/pubmed/29326145   AHA Podcast on the Survivorship Scientific Statement: https://soundcloud.com/americanheartstroke/podcast-survivorship 

Drs. Teran and Abella discuss a hot-off-the-press survey study by Maciel CB et al (Critical Care Medicine, 2020), probing physician perspectives and practice on post-arrest neurologic assessment and prognostication. Do all of us follow the international guidelines for this phase of care? What are points of confusion in current “real world” practice?  Join us to answer these questions and hear about key action items for all of us who manage post-arrest care. Key reading: Neuroprognostication Practices in Postcardiac Arrest Patients: An International Survey of Critical Care Providers. Maciel CB, Barden MM, Youn TS, Dhakar MB, Greer DM. Crit Care Med. 2020 Feb;48(2):e107-e114. https://www.ncbi.nlm.nih.gov/pubmed/31939809

Drs. Abella and Teran discuss the scientific literature surrounding gender differences in care during and following cardiac arrest. From differences in bystander CPR provision for public cardiac arrests to post-arrest DNR status and cardiac catheterization; listen to hear more.   Key publications for this episode: Lindgren E et al. Gender differences in utilization of coronary angiography and angiographic findings after out-of-hospital cardiac arrest: A registry study. Resuscitation. 2019 Oct;143:189-195. https://www.ncbi.nlm.nih.gov/pubmed/31330199 Perman SM et al. Sex Differences in "Do Not Attempt Resuscitation" Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions. Clin Ther. 2019 Jun;41(6):1029-1037. https://www.ncbi.nlm.nih.gov/pubmed/31047712 Jeong JS et al. Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest. Am J Emerg Med. 2019 Apr;37(4):632-638. https://www.ncbi.nlm.nih.gov/pubmed/30563798 Blewer AL et al. Gender Disparities Among Adult Recipients of Bystander Cardiopulmonary Resuscitation in the Public. Circ Cardiovasc Qual Outcomes. 2018 Aug;11(8):e004710. https://www.ncbi.nlm.nih.gov/pubmed/30354377