THERAPEUTIC HYPOTHERMIA AND TEMPERATURE MANAGEMENT Volume 1, Number 3, 2011 ª Mary Ann Liebert, Inc. DOI: 10.1089/ther.2011.0011

Letter to the Editor

Response: The Use of Hypothermia Therapy in Cardiac Arrest Survivors Castre´n Maaret

Dear Editor: I applaud your introduction of this new journal, Therapeutic Hypothermia and Temperature Management. As we all know that cardiac arrest is one certain area in which therapeutic hypothermia has a proven place, I was pleased to see the review by Nair and Lundbye that was included in your inaugural issue. However, there was no mention of the new cooling method—transnasal evaporative cooling—in any of the discussion concerning induction of cooling and it was not included in Table 2. Moreover, Table 2 lists cooling methods that are not commercially available and/or have little to no clinical data published in peer-reviewed journals (e.g., Nasopharyngeal balloon catheter cooling, Intrapulmonary cooling), whereas transnasal evaporative cooling has both. I feel this novel method should be included in any review of methods for cooling in cardiac arrest. There have been numerous mentions of this transnasal evaporative cooling method at scientific meetings with subsequent publications in high-impact peer-reviewed journals. The development of transnasal evaporative cooling in an ovine model was initially published in 2008 (Wolfson et al., 2008), and this was followed the same year by publications of its use to facilitate cardiac recovery in a swine model of cardiac arrest (Tsai et al., 2008). Additional publications in porcine cardiac arrest models provided further evidence for the targeted brain cooling this method achieves (Boller et al., 2010) and the improvements in resuscitation outcomes that this may yield (Wang et al., 2010; Yu et al., 2010). Clinical trials were carried out in both the United States and Europe from 2007 to 2009. Two clinical reports of this new method were then published in August 2010 (Busch et al., 2010; Castre´n et al., 2010)—the latter of the two was a randomized, controlled clinical trial (RCT). The RCT was also publically registered in 2008 (, NCT00808236), and results have since been publically displayed. The results from the RCT led to its inclusion in the European Resuscitation Council’s 2010 updated recommendations on resuscitation; specifically, ‘‘transnasal evaporative cooling’’ is listed as an acceptable method by which to induce cooling (Deakin et al., 2010). Animal studies dating from the late 1980s demonstrated that even small reductions in brain temperature

can have a large impact on ischemic damage. Emerging studies indicate that cold reperfusion at the time of return of spontaneous circulation could alter the course of both neurologic and cardiac recovery. Transnasal evaporative cooling may provide us with a method to get closer to that goal!

Disclosure Statement No competing financial interests exist.

References Boller M, Lampe JW, Katz JM, Barbut D, Becker LB. Feasibility of intra-arrest hypothermia induction: a novel nasopharyngeal approach achieves preferential brain cooling. Resuscitation 2010;81:1025–1030. Busch H-J, Eichwede F, Fo¨ disch M, Taccone FS, Wo¨ bker G, Schwab T, Hopf H-B, Tonner P, Hachimi-Idrissi S, Martens P, Fritz H, Bode Ch, Vincent J-L, Inderbitzen B, Barbut D, Sterz F, Janata A. Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest. Resuscitation 2010;81: 943–949. Castre´n M, Nordberg P, Svensson L, Taccone F, Vincent J-L, Desruelles D, Eichwede F, Mols P, Schwab T, Vergnion M, Storm C, Pesenti A, Pachl J, Gue´risse F, Elste T, Roessler M, Fritz H, Durnez P, Busch H-J, Inderbitzen B, Barbut D. Intra-arrest trans-nasal evaporative cooling: a randomized pre-hospital multi-center study: PRINCE (Pre-ROSC Intra Nasal Cooling Effectiveness). Circulation 2010;122: 729–736. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins GD. European Resuscitation Council Guidelines for Resuscitation 2010. Section 4. Adult advanced life support. Resuscitation 2010;81:1305–1352. Tsai MS, Barbut D, Tang W, Wang H, Guan J, Wang T, Sun S, Inderbitzen B, Weil MH. Rapid head cooling initiated coincident with cardiopulmonary resuscitation improves success of defibrillation and post-resuscitation myocardial function in a porcine model of prolonged cardiac arrest. J Am Coll Cardiol 2008 20;51:1988–1990. Wang H, Barbut D, Tsai MS, Sun S, Weil MH, Tang W. Intraarrest selective brain cooling improves success of resuscitation

Department of Clinical Science and Education, So¨dersjukhuset Karolinska Institutet, Stockholm, Sweden.


116 in a porcine model of prolonged cardiac arrest. Resuscitation 2010;81:617–621. Wolfson MR, Malone DJ, Wu J, Hoffman J, Rozenberg A, Shaffer TH, Barbut D. Intranasal perfluorochemical spray for preferential brain cooling in sheep. Neurocrit Care 2008;8:437–447. Yu T, Barbut D, Ristagno G, Cho JH, Sun S, Li Y, Weil MH, Tang W. Survival and neurological outcomes after nasopharyngeal cooling or peripheral vein cold saline infusion initiated during CPR in a porcine model of prolonged cardiac arrest. Crit Care Med 2010;38:916–921.

LETTER TO THE EDITOR Address correspondence to: Maaret Castre´n, M.D. Karolinska Institutet Department of Clinical Science and Education So¨dersjukhuset Sjukhusbacken 10 118 83 Stockholm Sweden E-mail: [email protected]

Response: the use of hypothermia therapy in cardiac arrest survivors.

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