What is the recommended protocol for targeted temperature management in post-cardiac arrest patients?

Targeted Temperature Management Protocol for Post-Cardiac Arrest Patients

For post-cardiac arrest patients who remain comatose after return of spontaneous circulation (ROSC), targeted temperature management (TTM) should be implemented with a constant target temperature between 32°C and 36°C for at least 24 hours. 1

Patient Selection

• Recommended for:

  • Out-of-hospital cardiac arrest (OHCA) with initial shockable rhythm (strong recommendation) 1
  • OHCA with initial non-shockable rhythm (weak recommendation) 1
  • In-hospital cardiac arrest (IHCA) with any initial rhythm (weak recommendation) 1
  • All patients in whom intensive care is continued are eligible 1

• Temperature Selection Considerations:

  • Higher temperatures within the range (36°C) might be preferred for patients with bleeding risk 1
  • Lower temperatures within the range (32-34°C) might be preferred for patients with clinical features worsened at higher temperatures (e.g., seizures, cerebral edema) 1
  • Initial patient temperature may influence selection - patients presenting at lower end of range may be maintained at that temperature 1

Implementation Protocol

Phase 1: Initiation

• Begin TTM as soon as possible after ROSC
• Do not use routine prehospital cooling with rapid infusion of cold intravenous fluids (Class III: No Benefit, LOE A) 1
• Use surface or endovascular temperature control techniques with feedback systems based on continuous temperature monitoring 1

Phase 2: Maintenance

• Maintain the selected target temperature (between 32-36°C) for at least 24 hours 1
• Ensure strict temperature control to prevent temperature fluctuations
• Monitor for and manage potential complications:
  • Bradycardia (may be beneficial and associated with good outcomes) 1
  • Electrolyte disturbances
  • Increased vasopressor requirements (more common with lower temperatures) 1
  • Seizures (EEG monitoring recommended)

Phase 3: Rewarming

• After completion of the maintenance phase, perform controlled rewarming
• Avoid rapid rewarming - use a controlled rate of 0.25-0.5°C per hour
• Actively prevent fever (temperature >37.5°C) for at least 72 hours in patients who remain comatose 1

Post-TTM Management

• Fever Prevention:

  • It may be reasonable to actively prevent fever in comatose patients after TTM (Class IIb, LOE C-LD) 1
  • Continue temperature monitoring and fever prevention for at least 72 hours after ROSC in patients who remain comatose 1
  • The simplest method to accomplish prolonged hyperthermia prevention may be to leave the devices or strategies used for TTM in place 1

• Seizure Management:

  • Do not use routine seizure prophylaxis 1
  • Monitor for seizures (prevalence 12-22% in post-cardiac arrest comatose patients) 1
  • Promptly treat seizures if they occur 1

Important Considerations and Pitfalls

• Avoid hypoxia and hyperoxia in patients with ROSC after cardiac arrest 1
• Maintain PaCO₂ within normal physiological range as part of post-ROSC care 1
• Do not actively warm comatose patients with mild hypothermia after ROSC to achieve normothermia 1
• Avoid prognostication too early - the earliest time to prognosticate poor neurologic outcome is 72 hours after ROSC 1
• Do not allow patients to warm to temperatures above 36°C during the TTM period as this would be inconsistent with current recommendations 1
• Do not rely on clinical criteria alone before 72 hours after ROSC to estimate prognosis 1

By following this protocol, clinicians can optimize the implementation of TTM in post-cardiac arrest patients to improve neurological outcomes and survival.