Update in Critical Care

Update in Critical Care

John M. Luce, MD

From University of California, San Francisco, and San Francisco General Hospital, San Francisco, California.

2003–2004 Series: Update Sessions from ACP's 2003 Annual Session

This year's Update in Critical Care incorporates 9 recent manuscripts that fall into a wide range of categories covered by critical care medicine, including cardiac arrest, pulmonary embolism, the acute respiratory distress syndrome, aspergillosis, sepsis and septic shock, bacterial meningitis, carbon monoxide poisoning, and methanol poisoning. All provide evidence that could change standard diagnosis or treatment procedures.

Cardiac Arrest

Mild Hypothermia Treatment Appeared To Be Beneficial for Survivors of Ventricular Fibrillation

Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002; 346:549-56. [PMID: 11856793]

Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346:557-63. [PMID: 11856794]

Cardiac arrest due to ventricular fibrillation can cause severe neurologic damage. The first of these 2 studies, a randomized, controlled trial, studied whether mild systemic hypothermia improved neurologic recovery after resuscitation from cardiac arrest due to ventricular fibrillation. All of the 273 participants had experienced ventricular fibrillation with successful resuscitation before being exposed to hypothermia. Medical staff covered the 136 patients in the hypothermia group with a cooling blanket after emergency department arrival and did not cover the 137 controls. The purpose of the cooling blanket was to reduce core temperature to 32 to 34 °C, as measured with a thermometer in the bladder. If the cooling blanket was not adequate, ice packs were applied to the groin and armpits. Treatment lasted 24 hours, after which patients returned to normothermia passively.

The authors used the Glasgow Outcome Scale to measure neurologic outcomes and deemed scores of 4 or 5 acceptable responses to treatment. Some patients who scored 4 (moderate recovery) or 5 (good recovery) still required rehabilitation for mild to moderate disabilities. Overall, 75 participants in the treatment group (55%) scored a 4 or a 5, compared with only 54 participants in the control group (39%). These results translated into lower mortality rates in the treatment group compared with the control group (6-month mortality rate, 41% vs. 55%). Complications from hypothermia treatment were rare, and complication rates were similar between the 2 groups.

In …

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