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Rewarming: The neglected phase of targeted temperature management

  • Niklas Nielsen
    Correspondence
    Corresponding author at: Lund University, Department of Clinical Sciences, Helsingborg Hospital, Svartbrödragränden 3-5, 251 87 Helsingborg, Sweden.
    Affiliations
    Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesiology and Intensive Care, Helsingborg, Sweden
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  • Hans Kirkegaard
    Affiliations
    Research Center for Emergency Medicine and Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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      Targeted temperature management (TTM) after cardiac arrest has been in clinical practice for almost two decades since the first randomized human evidence emerged in 2002.
      • Bernard S.A.
      • Gray T.W.
      • Buist M.D.
      • et al.
      Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.
      • Hypothermia after Cardiac Arrest Study G
      Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest.
      Today international guidelines recommend TTM for out-of-hospital cardiac arrest (OHCA) with the stronger recommendations for initial shockable rhythms.
      • Nolan J.P.
      • Soar J.
      • Cariou A.
      • et al.
      European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015.
      The recommendations for OHCA are however based on low-quality evidence and for in-hospital cardiac arrests (IHCA) on very low-quality evidence. Since the last iteration of guidelines 2015 and maybe also as an effect of the TTM-trial 2013,
      • Nielsen N.
      • Wetterslev J.
      • Cronberg T.
      • et al.
      Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest.
      the overall use of TTM has decreased.
      • Bradley S.M.
      • Liu W.
      • McNally B.
      • et al.
      Temporal trends in the use of therapeutic hypothermia for out-of-hospital cardiac arrest.
      • Abazi L.
      • Awad A.
      • Nordberg P.
      • et al.
      Long-term survival in out-of-hospital cardiac arrest patients treated with targeted temperature control at 33 degrees C or 36 degrees C: a national registry study.
      However recently an almost 600-patient randomized clinical trial (RCT) suggested better neurological outcome for patients with initial non-shockable rhythms in a population of both IHCA and OHCA when cooled to 33 °C.
      • Lascarrou J.B.
      • Merdji H.
      • Le Gouge A.
      • et al.
      Targeted temperature management for cardiac arrest with nonshockable rhythm.
      There are also ongoing trials that will further shed light on the future role of TTM.
      • Dankiewicz J.
      • Cronberg T.
      • Lilja G.
      • et al.
      Targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2): a randomized clinical trial-rationale and design.
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