Lessons From the Resuscitation Sessions at AHA

Lance B. Becker, MD; Graham Nichol, MD, MPH


January 23, 2014

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Graham Nichol, MD, MPH: Hello, and welcome to the late-breaking clinical trials discussion on on Medscape. I'm Graham Nichol, from the University of Washington Harborview Center for Prehospital Emergency Care. I'm here with my friend, colleague, and collaborator Lance Becker.

Lance B. Becker, MD: I'm Lance Becker from the University of Pennsylvania, and a long-time American Heart Association volunteer.

Graham, let's think a little bit about the 2 studies. There were 2 studies presented yesterday that were both negative. You were involved in one of those studies.[1] It involved the use of prehospital iced saline as a way to cool individuals down after cardiac arrest. That turned out to be a neutral study. Some thoughts from you in terms of what that means for us at this point?

Dr. Nichol: I think what it means is that although data in animals[2] and some pilot studies[3] were promising and suggested that cooling patients in the field rapidly with 2 L of iced saline after they've been resuscitated from cardiac arrest would improve their survival and neurologic outcome, Francis Kim and my colleagues in Seattle demonstrated that it did not.

We've learned a couple of things from that. First of all, we've learned that it is possible to do cardiac arrest trial in the United States. It is a little difficult to do them in the current environment. For clinicians, we've learned that we should not be encouraging paramedics to cool these patients with cold fluid. It may be that other methods of cooling work in the field. It may be that earlier methods of cooling work in the field, but until there is evidence of benefit, I think that ongoing efforts to cool in the field should stop.

Dr. Becker: I have to ask one follow-up question. Many of us in our hospitals and our emergency departments use the same exact cooling technique -- that is, 2 L of ice-cold saline, usually given fairly rapidly. It appeared to me that there were some adverse events that might have taken place as a result of that practice. What are your thoughts or your cautions to clinicians who are using that methodology?

Dr. Nichol: That's an interesting question. We observed that there was a temporary increase in pulmonary edema manifesting on radiography and manifesting in terms of diuretic use. It resolved by 48 hours, but I don't think that necessarily applies to use of cold fluid in hospital. The timing of giving the fluid would be different (vs in the field). The way it would be given would be different. I don't think we can extrapolate from the field to the hospital.

Dr. Becker: I'm in agreement with you, but I must say for my own practice, with a slight increase in the rate of rearrest and the pulmonary edema, I think that's something that we may need to begin to think about.

Dr. Nichol: We certainly need to think about it, yes. And if I had another method of cooling readily available in hospital, I would use that over cold saline intravenously.

I continue to believe that rapid initiation of cooling is important. I think we need to think a little bit more about the timing and the dose and duration, and I think some of our thoughts on that might be reflected by the other study that was presented. Can you summarize that one?


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