J Neurocrit Care.  2020 Jun;13(1):1-18. 10.18700/jnc.200001.

Targeted temperature management for postcardiac arrest syndrome

• Kuroda Y
• Kawakita K

• KMID: 2503381
• DOI: http://doi.org/10.18700/jnc.200001

Abstract

Neurocritical care management to improve neurologic outcome for postcardiac arrest syndrome (PCAS) has focused considerably on targeted temperature management (TTM). TTM attenuates the destructive processes following ischemia/reperfusion in PCAS. The principal indication of TTM is a patient with sustained coma after return of spontaneous circulation (ROSC). TTM can be strongly recommended with a target temperature between 32 and 36°C for patients with shockable rhythm and out of hospital cardiac arrest (OHCA) and weakly recommended for patients with initial asystole or pulseless electrical activity with OHCA and those with in-hospital cardiac arrest. TTM is induced and maintained using a cooling device with body temperature feedback under appropriate analgosedation. It requires the intensive management of various systemic respiratory, circulatory, and metabolic parameters that control shivering to prevent secondary brain damage. Considering the cerebral perfusion pressure, it is suggested that the mean arterial pressure should be particularly maintained over 80 mm Hg. Seizure management, including continuous electroencephalography monitoring, is also needed. Finally, we must continue the above mentioned care during and after the rewarming phase, because high fever and shivering may appear again during this period. Furthermore, neurological prognostication should be performed at least 72 hours after ROSC through clinical investigations and multimodal testing without sedation.

Keyword

Targeted temperature management; Neurocritical care; Shivering control; Brain injuries

Figure

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  Fig. 1. Definition of targeted temperature management.

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  Fig. 2. Special considerations before and during targeted temperature management (TTM) induction. ROSC, return of spontaneous circulation; GCS, Glasgow Coma Scale; ECPR, extracorporeal cardiopulmonary resuscitation; CT, computed tomography; ICU, intensive care unit. a)Coronary angiography with percutaneous coronary intervention for ST-elevated myocardial infarction.

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  Fig. 3. Shivering control and analgosedation. TTM, targeted temperature management; EEG, electroencephalography; BSAS, bedside shivering assessment scale.

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  Fig. 4. Systemic considerations during the maintenance phase of targeted temperature management (TTM). cEEG, continuous electroencephalography; NPi, neurological pupil index; MAP, mean arterial pressure; CPR, cardiopulmonary resuscitation; ECPR, extracorporeal cardiopulmonary resuscitation.

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  Fig. 5. Special considerations during the rewarming phase of targeted temperature management. cEEG, continuous electroencephalography; NPi, neurological pupil index; ROSC, return of spontaneous circulation.

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