Shrestha Dhan Bahadur, Sedhai Yub Raj, Budhathoki Pravash, Gaire Suman, Adhikari Anurag, Poudel Ayusha, Aryal Barun Babu, Yadullahi Mir Wasey Ali, Dahal Khagendra, Kashiouris Markos G
Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA.
Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
Ann Med Surg (Lond). 2022 Jan 29;74:103327. doi: 10.1016/j.amsu.2022.103327. eCollection 2022 Feb.
The current guidelines recommend targeted temperature management (TTM) as part of the post-resuscitation care for comatose patients following out-of-hospital cardiac arrest. These recommendations are based on the weak evidence of benefit seen in the early clinical trials. Recent large multicentered trials have failed to show a meaningful clinical benefit of hypothermia, unlike the earlier studies. Thus, to fully appraise the available data, we sought to perform this systematic review and meta-analysis of randomized controlled trials.
We searched four databases for randomized controlled trials comparing therapeutic hypothermia (32-34 °C) with normothermia (≥36 °C with control of fever) in adult patients resuscitated after out-of-hospital cardiac arrest. Independent reviewers did the title and abstract screening, full-text screening, and extraction. The primary outcome was mortality six months after cardiac arrest, and secondary outcomes were neurological outcomes and adverse effects.
Six randomized controlled trials were included in this review. There was no significant difference between the hypothermia and normothermia groups in mortality till 6 months follow up after out-of-hospital cardiac arrest (OR 0.88, 95% CI 0.67-1.16; n = 3243; I = 51%), or favorable neurological outcome (OR 1.31, 95% CI 0.93-1.84; n = 3091; I = 68%). Rates of arrhythmias were notably higher in the hypothermia group than the normothermia group (OR 1.43, 95% CI 1.20-1.71; n = 3029; I = 4%). However, odds for development of pneumonia showed no significant differences across two groups (OR 1.13, 95% CI 0.98-1.31; n = 3056; I = 22%). Therefore, targeted hypothermia with a target temperature of 32-34 °C does not provide mortality benefit or better neurological outcome in patients resuscitated after the out-of-hospital cardiac arrest when compared with normothermia.
当前指南推荐将目标温度管理（TTM）作为院外心脏骤停后昏迷患者复苏后护理的一部分。这些建议基于早期临床试验中所见益处的薄弱证据。与早期研究不同，近期大型多中心试验未能显示低温有显著的临床益处。因此，为全面评估现有数据，我们试图对随机对照试验进行这项系统评价和荟萃分析。
我们在四个数据库中检索了比较治疗性低温（32 - 34°C）与正常体温（≥36°C并控制发热）在院外心脏骤停后复苏的成年患者中的随机对照试验。独立评审员进行标题和摘要筛选、全文筛选及数据提取。主要结局是心脏骤停后六个月的死亡率，次要结局是神经学结局和不良反应。
本评价纳入了六项随机对照试验。在院外心脏骤停后直至6个月随访时，低温组和正常体温组在死亡率方面无显著差异（比值比0.88，95%置信区间0.67 - 1.16；n = 3243；I² = 51%），在良好神经学结局方面也无显著差异（比值比1.31，95%置信区间0.93 - 1.84；n = 3091；I² = 68%）。低温组心律失常发生率显著高于正常体温组（比值比1.43，95%置信区间1.20 - 1.71；n = 3029；I² = 4%）。然而，两组间肺炎发生几率无显著差异（比值比1.13，95%置信区间0.98 - 1.31；n = 3056；I² = 22%）。因此，与正常体温相比，目标温度为32 - 34°C的目标性低温对院外心脏骤停后复苏的患者并无死亡率益处或更好的神经学结局。
