Article

Successful use of targeted temperature management in pregnancy after out-of-hospital cardiac arrest

Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Successful use of targeted temperature management in pregnancy after out-of-hospital cardiac arrest?

Abstract

targeted temperature management may be considered on an individual basis after cardiac arrest in a comatose pregnant patient. The only 3 cases published so far describing the use of TTM in this setting have conflicting results in terms of fetal outcome.

A 31-year-old pregnant woman with a medical history significant for inherited long QT syndrome was admitted to the emergency depart- ment after an out-of-hospital cardiac arrest. After return of spontaneous circulation and admission to intensive care unit, TTM was started to maintain a body temperature of 34?C.

The mother had a Good neurologic outcome with a Modified Rankin scale of 1 at discharge and 0 at 6 months. The infant was delivered via cesarean section at 39 weeks’ gestation. Apgar scores were 8 and 9.

This is a successful application of TTM with a milder degree of cooling (34?C) compared with the published cases in a pregnant patient who subsequently had an uncomplicated delivery of her fetus, with no neurologic or developmental defects at follow-up.

The 2010 American Heart Association guidelines for cardiac arrest in special situations recommend that targeted temperature management may be considered on an individual basis after cardiac arrest in a comatose pregnant patient [1]. However, only 3 cases have been published to date describing the use of TTM with a degree of cooling of 33?C in this setting, with conflicting results in terms of fetal out- come [2-4].

The optimal approach to inducing, maintaining, and discontinuing this treatment remains unclear [5]. Specifically, based on the available human studies [6-8], decisions about which temperature to target after out-of-hospital cardiac arrest (OHCA) require careful consideration. Compared with previously published cases, we report the successful application of TTM with a milder degree of cooling (34?C) in a 13 weeks’ pregnant woman, who subsequently had an uncomplicated delivery of her fetus, with no neurologic or developmental defects at follow-up.

A 13-week-pregnant 31-year-old woman with a medical history sig- nificant for inherited Long QT syndrome was taken to the emergency de- partment by her husband after an OHCA that occurred while she was in the car. Advanced cardiac life support protocol was immediately started. Ventricular fibrillation was the first recorded cardiac rhythm. During

? MN performed the data collection. VDS drafted the manuscript. VDS, CN, and MF gave critical overview and input into the final manuscript version. All authors read and ap- proved the final manuscript. This study was supported by internal funding. There are no conflicts of interest to report.

resuscitation, she received a total of 3 shocks; epinephrine, 2 mg; and amiodarone, 300-mg bolus, with return of spontaneous circulation (ROSC) approximately 20 minutes after the arrest.

Upon arrival to the emergency department, the patient’s tempera- ture was 36.0?C, toxicological tests were negative, and initial neurologic examination revealed a Glasgow Coma Scale of 3. A 12-lead electrocar- diogram performed after ROSC showed sinus tachicardia, whereas on echocardiography, global and regional contractility was normal, with mild mitral prolapse, and no signs of effusion or right ventricular dys- function. Transabdominal ultrasound revealed a live intrauterine preg- nancy with fetal Cardiac activity (140-160 beats per minute).

The patient was admitted to intensive care unit, and after discussion of the risks and benefits, the family agreed to start TTM. During the pro- tocol, sedation was provided by midazolam infusion, and Neuromuscular paralysis was achieved with rocuronium at standard doses. Hypothermia was achieved by cutaneous ice packs followed by application of a ther- mal regulation system (Zoll Coolguard 3000) to maintain a body temper- ature of 34?C.

Daily fetal Ultrasonographic evaluations revealed no obvious abnormalities. Fetal bradycardia with a rate of 90 to 100 beats per minute was noted, as the patient reached goal temperature. The patient was rewarmed according to the established protocol for 24 hours, and the hourly temperature is shown in the Figure. Sedation was discontinued, and the patient awoke without any neurologic deficit on hospital day 2.

A repeated 12-lead electrocardiogram confirmed a long QT syn-

drome, and given the underlying increased risk for recurrent cardiac ar- rest, the patient received an Implantable cardioverter defibrillator on the 11th hospital day.

A cesarean section was performed at 39 weeks’ gestation for nonreassuring fetal status. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively.

The infant assessment at discharge and at 3 and 6 months showed a normal neurodevelopment. The mother had a good neurologic outcome with a modified Rankin scale of 1 at discharge and 0 at 6 months.

Cardiac arrest related to pregnancy is a Rare condition in the devel-

oped countries, occurring in an estimated 1:30000 deliveries in United Kingdom [9] and in 1:12000 hospitalizations for delivery in the United States [10]. This rareness is reflected by the paucity of data available in the medical literature regarding the management of such condition. Our case describes the successful use of TTM with a higher target temperature (34?C) compared with the only 2 cases published so far (33?C).

The most beneficial target temperature for therapeutic hypothermia after cardiac arrest is still unclear. Temperatures of 32?C to 34?C have been tested in 2 randomized trials [7,8]; however, similar results have

0735-6757/(C) 2015

Image of Figure

Figure. Patient temperature (degree Celsius) starting from ROSC, during TTM, and rewarming.

been observed with milder cooling [6]. Furthermore, whole-body hypo- thermia influences all organ systems, and any potential benefit should be balanced against possible side effects. In our case, we aimed for a 34?C target temperature to obtain an adequate Cerebral protection of the mother without affecting the fetus Organ functions with a lower temperature.

In a recent observational study in patients affected by an OHCA, a higher baseline temperature before initiation of TTM and a slower rate of cooling were associated with improved survival and neurologic out- comes [5]. Our results are in line with these findings, as the patient had a baseline temperature and a rate of cooling similar to the cohort with better outcomes in the study of Lin et al [5].

The successful outcome of patients with an OHCA is multifactorial. An important meta-analysis [11] reported a higher survival rate among certain categories of patients with an OHCA: witnessed by a by- stander, witnessed by emergency medical services (4.9%-18.2%), who received bystander cardiopulmonary resuscitation (3.9%-16.1%), with detected Ventricular fibrillation/ventricular tachycardia (14.8%-23.0%), or who achieved ROSC (15.5%-33.6%). Furthermore, data from a recent study [12] showed that 30-day survival after OHCA is higher in patients aged 18 to 65 years compared with older patients.

The successful outcome of our case might be in part explained by the presence of strong predictors of survival such as a bystander-witnessed OHCA in a young woman with ventricular fibrillation. Although the pa- tient did not receive bystander cardiopulmonary resuscitation, she ex- perienced the cardiac arrest in the car; therefore, the time interval to the emergency department arrival should have been reasonably short. Our case showed further evidence that, in pregnant patients experiencing ROSC after cardiac arrest, milder degrees of TTM (34?C) are reasonably safe and may provide benefits in terms of neurologic out-

come without adverse effects to the fetus.

Vincenzo De Santis, MD* Manuela Negri, MD

Department of Anesthesia and Intensive Care Medicine, Ospedale Santa Maria Delle Croci, AUSL Romagna, Viale Randi 5, 48121

Ravenna, Italy

*Corresponding author. Tel.: +39 0545 214164

fax: +39 0545 214171

E-mail address: [email protected]

[email protected]

Cecilia Nencini, MD

Azienda Ospedaliera San Camillo Forlanini, Circonvallazione

Gianicolense 87, 00152, Rome, Italy E-mail address: [email protected]

Maurizio Fusari, MD Department of Anesthesia and Intensive Care Medicine, Ospedale Santa Maria Delle Croci, AUSL Romagna, Viale Randi 5, 48121

Ravenna, Italy E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2015.05.049

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