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Therapeutic Hypothermia After Out-Of-Hospital Cardiac Arrest in Finnish Intensive Care Units: the FINNRESUSCI Study

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Therapeutic Hypothermia After Out-Of-Hospital Cardiac Arrest in Finnish Intensive Care Units: the FINNRESUSCI Study Intensive Care Med (2013) 39:826–837 DOI 10.1007/s00134-013-2868-1 ORIGINAL Jukka Vaahersalo Therapeutic hypothermia after out-of-hospital Pamela Hiltunen Marjaana Tiainen cardiac arrest in Finnish intensive care units: Tuomas Oksanen Kirsi-Maija Kaukonen the FINNRESUSCI study Jouni Kurola Esko Ruokonen Jyrki Tenhunen Tero Ala-Kokko Vesa Lund Matti Reinikainen Outi Kiviniemi Tom Silfvast Markku Kuisma Tero Varpula Ville Pettila¨ the FINNRESUSCI Study Group J. Tenhunen Abstract Purpose: We aimed to Received: 20 January 2012 Department of Surgical Sciences/ Accepted: 22 January 2013 evaluate post-resuscitation care, Published online: 16 February 2013 Anaesthesiology and Intensive Care Medicine, Uppsala University, implementation of therapeutic hypo- Ó Springer-Verlag Berlin Heidelberg and thermia (TH) and outcomes of ESICM 2013 Uppsala, Sweden intensive care unit (ICU)-treated out- Preliminary results of this study were T. Ala-Kokko of-hospital cardiac arrest (OHCA) presented at the ESICM Annual Congress, Department of Anaesthesiology, patients in Finland. Methods: We Berlin, Germany 2011. Division of Intensive Care, included all adult OHCA patients Oulu University Hospital, admitted to 21 ICUs in Finland from The members of the FINNRESUSCI Study Oulu, Finland Group are presented in the ‘‘Appendix’’. March 1, 2010 to February 28, 2011 in this prospective observational study. Electronic supplementary material V. Lund The online version of this article Department of Anaesthesiology Patients were followed (mortality and (doi:10.1007/s00134-013-2868-1) contains and Intensive Care Medicine, neurological outcome evaluated by supplementary material, which is available Satakunta Central Hospital, Cerebral Performance Categories, to authorized users. Pori, Finland CPC) within 1 year after cardiac arrest. Results: This study included M. Reinikainen Department of Anaesthesiology 548 patients treated after OHCA. Of J. Vaahersalo Á T. Oksanen Á and Intensive Care Medicine, those, 311 patients (56.8 %) had a K.-M. Kaukonen Á T. Varpula Á V. Pettila¨ North Karelia Central Hospital, shockable initial rhythm (incidence of Department of Surgery, Intensive Care Joensuu, Finland 7.4/100,000/year) and 237 patients Units, Helsinki University Hospital, (43.2 %) had a non-shockable rhythm Helsinki, Finland O. Kiviniemi (incidence of 5.6/100,000/year). At Department of Anaesthesiology and ICU admission, 504 (92 %) patients P. Hiltunen Á J. Kurola Á E. Ruokonen Intensive Care Medicine, Lappi Central Division of Intensive Care Medicine, Hospital, Rovaniemi, Finland were unconscious. TH was given to Kuopio University Hospital, 241/281 (85.8 %) unconscious Kuopio, Finland T. Silfvast Á M. Kuisma patients resuscitated from shockable Emergency Medical Service, rhythms, with unfavourable 1-year M. Tiainen Helsinki University Central Hospital, neurological outcome (CPC 3–4–5) in Department of Neurology, Helsinki Helsinki, Finland 42.0 % with TH versus 77.5 % with- University Hospital, Helsinki, Finland out TH (p \ 0.001). TH was given to J. Vaahersalo ()) J. Tenhunen Department of Intensive Care Medicine, 70/223 (31.4 %) unconscious patients Department of Intensive Care Medicine, Helsinki University Hospital, resuscitated from non-shockable Critical Care Medicine Research Group, Helsinki, Finland rhythms, with 1-year CPC of 3–4–5 in Tampere University Hospital, Tampere, e-mail: jukka.vaahersalo@hus.fi 80.6 % (54/70) with TH versus Finland Tel.: ?358-50-4271736 84.0 % (126/153) without TH 827 (p = 0.56). This lack of difference shockable rhythms after TH was Keywords Out-of-hospital remained after adjustment for pro- lower than in previous randomized cardiac arrest Á Therapeutic pensity to receive TH in patients with controlled trials. However, our results hypothermia Á Mortality Á Outcome non-shockable rhythms. Conclu- do not support use of TH in patients sions: One-year unfavourable with non-shockable rhythms. neurological outcome of patients with Introduction Patients, sample size and treatment Therapeutic hypothermia (TH) has been shown to The study protocol was approved by the Ethics Com- improve outcome of patients resuscitated from out-of- mittee of each participating hospital. Inclusion criteria for hospital cardiac arrest (OHCA) caused by ventricular the study were: (1) OHCA, (2) successful resuscitation, fibrillation (VF) or pulseless ventricular tachycardia (VT) (3) age over 18 years and (4) post-resuscitation care in [1, 2]. Thus, TH is the main therapeutic intervention of one of the participating ICUs. post-resuscitation care, with a strong recommendation Based on the national FICC database, there are 17,000 based on evidence in OHCA patients resuscitated from ICU admissions including approximately 800 cardiac VF/VT [3]. Previous retrospective studies have reported arrest patients per year. We estimated that, of those 800 large variations in the degree of implementation of TH patients, 600 would be OHCA patients, which would [4–7]. In Finland the degree of implementation of TH was provide an adequate sample size for a precise [95 % 28 % in 2006 in all cardiac arrest patients, and 33 % in confidence interval (CI) ±1/100,000] assessment of the OHCA patients treated in ICU [6]. population-based incidence of OHCA, and comparison To date, no randomized controlled trials (RCT) on TH between incidences of OHCA with shockable and non- in patients resuscitated from non-shockable rhythms are shockable rhythms. With this sample size, we assumed to available, and thus its possible effects on outcome are not include 300 OHCA-VF patients treated with TH. The known [8, 9]. Regardless of insufficient evidence, TH has proportions of OHCA patients with non-shockable rhythm been recommended for all OHCA patients chosen for treated and not treated with TH were not possible to active intensive care [3, 10]. However, neither the clinical predict. Thus, a study period of 1 year was set, from implementation of this recommendation, nor the outcome March 1, 2010 to February 28, 2011. of these patients treated with TH is known. Furthermore, In this observational prospective study no recom- as the incidence of out-of-hospital ventricular fibrillation mendations for treatment of post-resuscitation syndrome (VF) has been decreasing during the past years also in [13, 14] and post-resuscitation care were given. National Finland [11, 12], the use of TH in patients resuscitated and European Resuscitation Councils (ERC) guidelines of from non-shockable rhythms may have increased. post-resuscitation care [15, 16], national handbook of Accordingly, in this nationwide prospective cohort intensive care [17] and local ICUs’ standard operational study we aimed to evaluate post-resuscitation care, the protocols were used according to the decisions by the use and implementation of TH and outcome of all adult treating physicians. According to the Finnish intensive OHCA patients admitted to Finnish intensive care units care handbook [17], TH is indicated only if: (1) cardiac (ICUs). Our secondary aim was to determine the popu- arrest is witnessed, (2) initial rhythm is VF or VT and (3) lation-based incidence of OHCA. patient is unconscious at hospital or ICU admission. Recent Scandinavian [10] and also the latest guidelines of the ERC 2010 [3] have recommended that TH should be considered also for patients from non-shockable rhythms Methods if active treatment is chosen in the ICU. Techniques of induction or maintenance of TH were Participating ICUs not restricted. The majority of Finnish ICUs use endo- vascular cooling devices. We collected reasons if TH was All 22 Finnish ICUs treating OHCA patients were asked not used in patients resuscitated from shockable rhythms. to participate in this study. In total 21, all five university hospitals with 7 ICUs, and 14 out of 15 central hospital ICUs consented to participate in this study. Approxi- Data collection mately 98 % of the Finnish adult population (4.3 million www.stat.fi) live in the referral areas of these ICUs. All We collected data of study patients prospectively by using these ICUs belong to the Finnish Intensive Care Con- Internet-based case report forms (CRFs). We obtained sortium (FICC). pre-existing diagnoses of diabetes, coronary artery 828 disease, hypertension, pacemaker, previous coronary artery or pulseless electrical activity (PEA)], time to return of bypass surgery (CABG), chronic heart failure or renal spontaneous circulation (ROSC), witnessed cardiac arrest failure from the patients’ medical history. The aetiology of (yes/no), bystander cardiopulmonary resuscitation (CPR) CA was determined according to Utstein criteria [18]. The (yes/no) and inclusion site as variables in the backwards FICC database was used for data collection and follow-up, logistic regression analysis to evaluate independent fac- including demographic data, haemodynamic data, Simpli- tors predicting TH. We calculated a propensity score for fied Acute Physiology Score (SAPS) II, Acute Physiology TH for each patient and then categorized the patients into and Chronic Health Evaluation (APACHE) II score, five groups according to the probability of TH. Thereafter, Therapeutic Intervention Scoring System (TISS) points, we performed a backwards logistic regression analysis to length of stay (LOS) in ICU and hospital mortality. Ninety- scrutinize independent factors associated with unfavour- day mortality was collected from Statistics Finland. One able outcome (CPC 3–4–5). We included the propensity specialist in neurology (M.T.) was blinded to treatment in score
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