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Has Targeted Temperature Management Gotten Lax?

December 12, 2018

Written by Clay Smith

Spoon Feed
Targeted temperature management (TTM) still requires active cooling to 36°C and meticulous avoidance of hyperthermia. Becoming lax in this may be associated with increased mortality.

Why does this matter?
First, there was therapeutic hypothermia (TH), with a 33°C goal. This gave way to TTM, which showed a 36°C goal was as good as 33°C. The TTM study was released early on November 17, 2013 and was rapidly adopted. It seemed the key wasn’t making post-arrest patients cold, rather near normal, with strict avoidance of hyperthermia. But have we now gone too far, and post-arrest patients aren’t having temperature management performed as meticulously?

TTM doesn’t mean no temperature management
This was a huge retrospective study of 16,250 patients with out-of-hospital-cardiac-arrest (OHCA) from 140 hospitals in NZ and Australia. They found that after publication of the TTM paper, the average temperature in the first 24 hours rose almost a degree from 33.8°C before TTM to 34.7°C after. More concerning, fever occurred in 12.8% during the TH era and rose to 16.5% after TTM adoption. In-hospital mortality was declining during the TH era and increased slightly (0.6%) after adoption of TTM. After TTM, it seems the higher goal of 36°C allowed for more breakthrough fever and may have contributed to increased mortality, although causality cannot be proven on the basis of this study.

Another Spoonful
EMCrit covered the TTM trial when it first came out in detail. Make sure to see this.

Changes in Temperature Management of Cardiac Arrest Patients Following Publication of the Target Temperature Management Trial. Crit Care Med. 2018 Nov;46(11):1722-1730. doi: 10.1097/CCM.0000000000003339.

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What are your thoughts?