Changes in Practice of Controlled Hypothermia after Cardiac Arrest in the Past 20 Years

Nielsen N, Friberg H. Am J Respir Crit Care Med. 2023 Apr 27. doi: 10.1164/rccm.202211-2142CP. Epub ahead of print. [CrossRef] [PubMed]

For 20 years, induced hypothermia and targeted temperaturemanagement have been recommended to mitigate brain injuryand increase survival after cardiac arrest. On the basis of animalresearch and small clinical trials, the International LiaisonCommittee on Resuscitation strongly advocated hypothermia at32–34C for 12–24 hours for comatose patients with out-of-hospital cardiac arrest with initial rhythm of ventricularfibrillation or nonperfusing ventricular tachycardia. Theintervention was implemented worldwide. In the past decade,hypothermia and targeted temperature management have beeninvestigated in larger clinical randomized trials focusing ontarget temperature depth, target temperature duration,prehospital versus in-hospital initiation, nonshockable rhythms,and in-hospital cardiac arrest. Systematic reviews suggest littleor no effect of delivering the intervention on the basis of thesummary of evidence, and the International Liaison Committeeon Resuscitation today recommends only to treat fever and keepbody temperature below 37.5C (weak recommendation,low-certainty evidence). Here we describe the evolution oftemperature management for patients with cardiac arrestduring the past 20 years and how the accrued evidence hasinfluenced not only the recommendations but also the guidelineprocess. We also discuss possible paths forward in this field,bringing up both whether fever management is at allbeneficial for patients with cardiac arrest and which knowledgegaps future clinical trials in temperature management should address. 

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