Some Cardiac Arrest Patients Get the Big Chill

February 2008 also introduced a more intensive, in-hospital program at Virginia Commonwealth: Advanced Resuscitation Cooling Therapeutics and Intensive Care (ARCTIC), modeled on a trauma-team approach. It involves a specialized team of providers trained to both continue TH and provide state-of-the-art resuscitation care. TH is continued in the hospital using an intravascular catheter that's threaded through the femoral vein and into the inferior vena cava. The catheter balloon contains a continuous flow of cold fluid that directly cools the patient's blood, so the target temperature of 33° C is reached within 1 hour, Dr. Peberdy said.

From February through mid-December 2008, 54 resuscitated cardiac arrest patients were treated this way, with 40%–45% surviving with good neurologic outcomes, compared with a historic rate without TH of about 15%, she reported in an interview. Dr. Peberdy, who is director of ARCTIC, credits this program and the EMS diversion policy with forcing the hand of at least one other Richmond hospital that introduced TH following the launch of Virginia Commonwealth's program in early 2008.

▸ TH began to be used comprehensively at Columbia-Presbyterian in New York in mid-2007, taking hold under the leadership of Dr. Mayer. By late 2007, he and other TH advocates in New York City organized a day-long hypothermia session that led to a year-long effort to make TH available to cardiac arrest patients around the city. The initiative got a boost when it was embraced by the medical directors of the city's EMS program and the fire department. The result is that starting this year, cardiac arrest patients who are picked up by ambulances inside the city and meet the requisite clinical parameters will be taken to the closet hospital that can provide TH as long as it can be reached within 20 minutes. The program also plans to start providing prehospital cooling in the ambulance during 2009.

▸ Boston Medical Center began using TH in 2004, and the other large medical centers in the Boston area have also begun its routine use. The program ratcheted up in mid-2008, when the Boston EMS program began administering TH to eligible patients while they were in the ambulance, said Dr. George Philippides, director of the coronary care unit at Boston Medical Center.

TH “is relatively easy to start in the field, using cold intravenous saline and ice packs. There is no valid reason not to adopt this practice,” Dr. Philippides said.

▸ A TH program for cardiac arrest began at the Ochsner Clinic in New Orleans in May 2007. As of late 2008, it wasn't clear whether TH was routinely used at other hospitals in New Orleans, said Dr. Christopher White, chairman of the department of cardiovascular diseases at Ochsner. He hopes that in 2009 a program may begin with the city's EMS to preferentially transport cardiac arrest patients to hospitals in the city that can deliver TH, a step that he predicted will likely not be controversial because “it is absolutely the right thing to do, and because we are talking about a small number of patients so hospital volume is not threatened,” Dr. White said.

▸ A standard protocol to use TH for cardiac arrest survivors began in 2003 at the University of Pittsburgh, and in 2008 the center treated more than 100 patients this way. Other hospitals in Pittsburgh have varying levels of TH use, said Dr. Callaway from the University of Pittsburgh. “We are now discussing whether it makes sense for EMS” to only take these patients to cardiac arrest centers, just as trauma patients are taken only to specializing centers, he said.

Broader use of TH could have a substantial clinical impact, according to an analysis published in 2008 by researchers at the University of Michigan, Ann Arbor (Resuscitation 2008; 77:189–94).

They assumed that EMS crews annually treated about 70 patients for out-of-hospital cardiac arrest for every 100,000 Americans, or roughly 200,000 U.S. patients a year. Assuming that about 20% of these patients have return of spontaneous circulation, and about a third of the resuscitated patients are eligible for TH, and applying the guide that six such patients need to be treated to have one improved outcome, then more than 2,000 additional Americans a year stand to survive with a good neurologic outcome if TH is routinely used for all eligible cardiac arrest patients.

Dr. Bentley J. Bobrow demonstrates insertion of an intravascular catheter used for cooling a resuscitated cardiac arrest patient. David Rose/Mayo Clinic Arizona

Therapeutic hypothermia is easy to start in the field. 'There is no valid reason not to adopt this practice.' DR. PHILIPPIDES