Extracorporeal cardiopulmonary resuscitation in accidental hypothermia

Blasco Mariño, R.; Martín Orejas, M.; González Posada, M.Á.; Soteras Martinez, Í.

doi:10.1016/j.redare.2021.11.005

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AH is a clinical entity defined as the unintentional lowering of core temperature <35°C. A primary diagnosis of hypothermia is usually not easy to reach without clearly precipitating environmental conditions, even in regions with a higher incidence and mortality from AH. Once diagnosed or suspected, management depends heavily on the patient's clinical manifestations and core temperature. In severe cases, where there is haemodynamic instability and an altered level of consciousness, or in cases of cardiorespiratory arrest (CRA), transfer to an ECMO centre for extracorporeal cardiopulmonary resuscitation (eCPR) is recommended, provided it can be performed in less than 6h<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.ECMO is the current gold standard for rewarming and supportive therapy. The use of extracorporeal systems provides survival data of 20%–100%, of which 61%–100% have good or moderate neurological outcomes at hospital discharge (Cerebral Performance Category 1–2)<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>. Despite these encouraging results, the decision to resuscitate and refer these patients can be complex, especially if we take into account that the indications and contraindications for eCPR in out-of-hospital CPR due to AH are not the same as for normothermic patients<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>.Evidence has recently been published that may help us to manage the particularities of this entity<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. Therefore, we would like to complement some aspects that should be considered in eCPR in patients with severe AH:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-In the case of CRA due to AH, the use of prognostic scales is recommended as a bridge to the decision of whether or not to continue CPR, thus avoiding futile actions. There are currently 2 scales: ICE and HOPE, the latter being the most widely used. Favourable values of these scales predict the probability of survival with eCPR. HOPE (hypothermiascore.org) values of less than 10% have a negative predictive value of 97% and, therefore, little probability of success below this cut-off point<a class="elsevierStyleCrossRef" href="#bib0030">6</a>. These scales take over from the old cut-off points for isolated potassium levels.</li><li class="elsevierStyleListItem" id="lsti0010">-The decision whether or not to perform eCPR should not be based on the existence of adverse blood gas values (pH<6.8). Findings on physical examination or monitoring that may simulate poor clinical prognosis or unequivocal signs of death (bilateral unresponsive mydriasis apparent rigor mortis, very low BIS values, EtCO2<10mmHg or systolic blood pressure<60mmHg) should not be used to stop or not perform eCPR.</li><li class="elsevierStyleListItem" id="lsti0015">-The decision to initiate eCPR should not follow the classical contraindications of the normothermic patient. A first heart rhythm in asystole, absence of chest compressions in the first 10min after the absence of vital signs, intermittent CPR, advanced age or unwitnessed CPR are not an absolute contraindication for eCPR. The usual rules of termination of resuscitation should not apply to AH cases: the axiom “no hypothermic victim in cardiac arrest is dead until he or she is warm and dead” prevails.</li><li class="elsevierStyleListItem" id="lsti0020">-There is currently no ideal rewarming rate. Current data indicate that slow rewarming provides survival data with better neurological outcomes. The rewarming target should be less than 5C/h, maintaining a veno-arterial temperature gradient, if possible, <4C and always less than 10C to avoid formation of gas emboli.</li><li class="elsevierStyleListItem" id="lsti0025">-During resuscitation, if the core temperature is <30C, a maximum of 3 defibrillations can be performed and the use of vasopressor drugs is not recommended. After 30C, it is recommended to double the pharmacological CPR intervals until 35C is reached and, from this point, follow standard protocols.</li><li class="elsevierStyleListItem" id="lsti0030">-eCPR should not be performed only in the following cases: existence of life-threatening injuries, severe associated comorbidities or chest incompressible due to frostbite. A core temperature >30C associated with the absence of vital signs makes a hypothermic origin of the episode highly improbable, so alternative causes must be assessed<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.</li></ul>Lastly, we would like to emphasise the importance of creating local multidisciplinary protocols for rare resuscitation situations. The implementation of standardised working structures and debriefing systems for all subjects in the AH chain of survival improves care and creates a favourable climate for proactive work<a class="elsevierStyleCrossRef" href="#bib0010">2</a>." 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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