Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation

From Cochrane Reviews:

Background

Good neurologic outcome after cardiac arrest is hard to achieve. Interventions during the resuscitation phase and treatment within the first hours after the event are critical. Experimental evidence suggests that therapeutic hypothermia is beneficial, and a number of clinical studies on this subject have been published.

Objectives

We performed a systematic review and meta-analysis to assess the effectiveness of therapeutic hypothermia in patients after cardiac arrest. Neurologic outcome, survival and adverse events were our main outcome parameters. We aimed to perform individual patient data analysis if data were available, and to from subgroups according to the cardiac arrest situation.

Search strategy

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007 Issue 1); MEDLINE (1971 to January 2007); EMBASE (1987 to January 2007); CINAHL (1988 to January 2007); PASCAL (2000 to January 2007); and BIOSIS (1989 to January 2007).

Selection criteria

We included all randomized controlled trials assessing the effectiveness of the therapeutic hypothermia in patients after cardiac arrest without language restrictions. Studies were restricted to adult populations cooled with any cooling method applied within six hours of cardiac arrest.

Data collection and analysis

Validity measures, the intervention, outcome parameters and additional baseline variables were entered into the database. Meta-analysis was only done for a subset of comparable studies with negligible heterogeneity. For these studies individual patient data were available.

Main results

Four trials and one abstract reporting on 481 patients were included in the systematic review. Quality of the included studies was good in three out of five included studies. For the three comparable studies on conventional cooling methods all authors provided individual patient data. With conventional cooling methods patients in the hypothermia group were more likely to reach a best cerebral performance categories score of one or two (CPC, five point scale; 1= good cerebral performance, to 5 = brain death) during hospital stay (individual patient data; RR, 1.55; 95% CI 1.22 to 1.96) and were more likely to survive to hospital discharge (individual patient data; RR, 1.35; 95% CI 1.10 to 1.65) compared to standard post-resuscitation care. Across all studies there was no significant difference in reported adverse events between hypothermia and control.

Authors’ conclusions

Conventional cooling methods to induce mild therapeutic hypothermia seem to improve survival and neurologic outcome after cardiac arrest. Our review supports the current best medical practice as recommended by the International Resuscitation Guidelines.

A randomized controlled trial comparing the Arctic Sun to standard cooling for induction of hypothermia after cardiac arrest

From Resuscitation:

Context

Hypothermia improves neurological outcome for comatose survivors of out-of-hospital cardiac arrest. Use of computer controlled high surface area devices for cooling may lead to faster cooling rates and potentially improve patient outcome.

Objective

To compare the effectiveness of surface cooling with the standard blankets and ice packs to the Arctic Sun, a mechanical device used for temperature management.

Design, setting, and patients

Multi-center randomized trial of hemodynamically stable comatose survivors of out-of-hospital cardiac arrest.

Intervention

Standard post-resuscitative care inducing hypothermia using cooling blankets and ice (n=30) or the Arctic Sun (n=34).

Main outcome measures

The primary end point was the proportion of subjects who reached a target temperature within 4h of beginning cooling. The secondary end points were time interval to achieve target temperature (34°C) and survival to 3 months.

Results

The proportion of subjects cooled below the 34°C target at 4h was 71% for the Arctic Sun group and 50% for the standard cooling group (p=0.12). The median time to target was 54min faster for cooled patients in the Arctic Sun group than the standard cooling group (p<0.01). Survival rates with good neurological outcome were similar; 46% of Arctic Sun patients and 38% of standard patients had a cerebral performance category of 1 or 2 at 30 days (p=0.6).

Conclusions

While the proportion of subjects reaching target temperature within 4h was not significantly different, the Arctic Sun cooled patients to a temperature of 34°C more rapidly than standard cooling blankets.

What does H1N1 pandemic flu as a national emergency mean?

From MedPage Today, posted on KevinMD:

The president’s move — combined with the earlier declaration of a public health emergency — gives Sebelius additional powers.

For example, the secretary can waive some of the rules governing Medicare and Medicaid under Section 1135 of the Social Security Act, as well as some of the privacy regulations under the Health Insurance Portability and Accountability Act.

The waivers have to be requested on a case-by-case basis, and officials at the Department of Health and Human Services were not able to say immediately how long such approval takes.

Among possible scenarios:

* A hospital might want to set up an alternative screening location for patients away from its main campus — a move that would need a waiver of the Emergency Medical Treatment and Labor Act.
* A critical access hospital might ask to be allowed more than 25 beds and hospital stays of longer than 96 hours — requiring a waiver of parts of the code of federal regulations.
* Hospitals might need to transfer patients for screening or before they have been stabilized — requiring waivers under both the emergency treatment and privacy laws.

N.Y. moving ahead on price-comparison database

From Modern Healthcare:

Using almost $100 million it received in settlement money from insurers, the state of New York created a not-for-profit company and an independent research network to develop a database and Web site that patients can use to compare prices for healthcare services, New York state Attorney General Andrew Cuomo announced.

The company is called Fair Health and the research network will be headquartered at Syracuse University, but will also include Cornell University, the State University of New York at Buffalo, SUNY Upstate Medical University and the University of Rochester. It will be led by Deborah Freund, a professor of public administration at Syracuse University.

Fair Health and the research network also will create a consumer Web site so patients can calculate how much they will be reimbursed for out-of-network healthcare services in their area, a news release said.

Cold saline infusion and ice packs alone are effective in inducing and maintaining therapeutic hypothermia after cardiac arrest

From Resuscitation:

Aim of the study

Hypothermia treatment with cold intravenous infusion and ice packs after cardiac arrest has been described and used in clinical practice. We hypothesised that with this method a target temperature of 32–34°C could be achieved and maintained during treatment and that rewarming could be controlled.

Materials and methods

Thirty-eight patients treated with hypothermia after cardiac arrest were included in this prospective observational study. The patients were cooled with 4°C intravenous saline infusion combined with ice packs applied in the groins, axillae, and along the neck. Hypothermia treatment was maintained for 26h after cardiac arrest. It was estimated that passive rewarming would occur over a period of 8h. Body temperature was monitored continuously and recorded every 15min up to 44h after cardiac arrest.

Results

All patients reached the target temperature interval of 32–34°C within 279±185min from cardiac arrest and 216±177min from induction of cooling. In nine patients the temperature dropped to below 32°C during a period of 15min up to 2.5h, with the lowest (nadir) temperature of 31.3°C in one of the patients. The target temperature was maintained by periodically applying ice packs on the patients. Passive rewarming started 26h after cardiac arrest and continued for 8±3h. Rebound hyperthermia (>38°C) occurred in eight patients 44h after cardiac arrest.

Conclusions

Intravenous cold saline infusion combined with ice packs is effective in inducing and maintaining therapeutic hypothermia, with good temperature control even during rewarming.

Chuck Grassley Has a Few Questions for the Health IT Industry

From the Wall Street Journal Health Blog:

Chuck Grassley — the Senator who spent years asking questions about doctors’ ties to the drug and device industries — has some questions for the health IT industry.

In letters sent earlier this month to 10 companies, Grassley says that he’s “received complaints” about systems that allow doctors to enter medical orders by computer. (Here’s a copy of the letter.) This is a big deal these days because the stimulus bill provides billions of dollars in federal incentives to encourage doctors and hospitals to start using these sorts of systems.

Grassley asks the companies to send him copies of “complaints and/or concerns” that health-care providers have expressed about the systems. He wants to know whether the companies typically include legal provisions in their contracts that “shift responsibility for errors in the … systems to physicians, nurses, pharmacists, and other health care providers.”