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    Original Investigation
    Critical Care Medicine
    July 23, 2020

    Association of Initial Illness Severity and Outcomes After Cardiac Arrest With Targeted Temperature Management at 36 °C or 33 °C

    Author Affiliations
    • 1Pittsburgh Post–Cardiac Arrest Service, Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
    JAMA Netw Open. 2020;3(7):e208215. doi:10.1001/jamanetworkopen.2020.8215
    Key Points español 中文 (chinese)

    Question  What is the optimal target temperature for targeted temperature management (TTM) in comatose patients after cardiac arrest?

    Findings  In a cohort study of 1319 patients, of whom 911 did not have severe cerebral edema or highly malignant electroencephalogram, TTM at 33 °C was associated with better survival than TTM at 36 °C for patients with the most severe post–cardiac arrest illness, but TTM at 36 °C was associated with better survival in patients with mild- to moderate-severity illness. Patients with severe cerebral edema or highly malignant electroencephalogram had poor outcomes regardless of TTM strategy.

    Meaning  The findings of this study suggest that measuring initial illness severity in patients resuscitated from cardiac arrest may guide selection of the optimal TTM strategy.


    Importance  It is uncertain what the optimal target temperature is for targeted temperature management (TTM) in patients who are comatose following cardiac arrest.

    Objective  To examine whether illness severity is associated with changes in the association between target temperature and patient outcome.

    Design, Setting, and Participants  This cohort study compared outcomes for 1319 patients who were comatose after cardiac arrest at a single center in Pittsburgh, Pennsylvania, from January 2010 to December 2018. Initial illness severity was based on coma and organ failure scores, presence of severe cerebral edema, and presence of highly malignant electroencephalogram (EEG) after resuscitation.

    Exposure  TTM at 36 °C or 33 °C.

    Main Outcomes and Measures  Primary outcome was survival to hospital discharge, and secondary outcomes were modified Rankin Scale and cerebral performance category.

    Results  Among 1319 patients, 728 (55.2%) had TTM at 33 °C (451 [62.0%] men; median [interquartile range] age, 61 [50-72] years) and 591 (44.8%) had TTM at 36 °C (353 [59.7%] men; median [interquartile range] age, 59 [48-69] years). Overall, 184 of 187 patients (98.4%) with severe cerebral edema died and 234 of 243 patients (96.3%) with highly malignant EEG died regardless of TTM strategy. Comparing TTM at 33 °C with TTM at 36 °C in 911 patients (69.1%) with neither severe cerebral edema nor highly malignant EEG, survival was lower in patients with mild to moderate coma and no shock (risk difference, –13.8%; 95% CI, –24.4% to –3.2%) but higher in patients with mild to moderate coma and cardiopulmonary failure (risk difference, 21.8%; 95% CI, 5.4% to 38.2%) or with severe coma (risk difference, 9.7%; 95% CI, 4.0% to 15.3%). Interactions were similar for functional outcomes. Most deaths (633 of 968 [65.4%]) resulted after withdrawal of life-sustaining therapies.

    Conclusions and Relevance  In this study, TTM at 33 °C was associated with better survival than TTM at 36 °C among patients with the most severe post–cardiac arrest illness but without severe cerebral edema or malignant EEG. However, TTM at 36 °C was associated with better survival among patients with mild- to moderate-severity illness.