Marine Paul1, Wulfran Bougouin2, Florence Dumas3, Guillaume Geri4, Benoit Champigneulle5, Lucie Guillemet6, Omar Ben Hadj Salem6, Stéphane Legriel7, Jean-Daniel Chiche1, Julien Charpentier6, Jean-Paul Mira1, Claudio Sandroni8, Alain Cariou9. 1. Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France. 2. Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France. 3. Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris, France. 4. Medical ICU, Cochin Hospital, AP-HP, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France. 5. Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Surgical & Trauma Intensive Care Unit, Georges Pompidou European Hospital, APHP, Paris, France. 6. Medical ICU, Cochin Hospital, AP-HP, Paris, France. 7. Paris Sudden-Death-Expertise-Center, Paris, France; ICU, Mignot Hospital, Le Chesnay, France. 8. Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy. 9. Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France. Electronic address: alain.cariou@cch.aphp.fr.
Abstract
PURPOSE: Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. METHODS: We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS: 460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. CONCLUSIONS: During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.
PURPOSE: Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. METHODS: We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS: 460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. CONCLUSIONS: During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.
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