Targeted temperature management guided by the severity of hyperlactatemia for out-of-hospital cardiac arrest patients : a post hoc analysis of a nationwide, multicenter prospective registry

Background: The International Liaison Committee on Resuscitation guidelines recommend target temperature management (TTM) between 32 and 36 °C for patients after out-of-hospital cardiac arrest, but did not indicate patient-specific temperatures. The association of serum lactate concentration and neurological outcome in out-of-hospital cardiac arrest patient has been reported. The study aim was to investigate the benefit of 32-34 °C in patients with various degrees of hyperlactatemia compared to 35-36 °C.

Methods: This study was a post hoc analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest registry between June 2014 and December 2015. Patients with complete targeted temperature management and lactate data were eligible. Patients were stratified to mild (< 7 mmol/l), moderate (< 12 mmol/l), or severe (≥ 12 mmol/l) hyperlactatemia group based on lactate concentration after return of spontaneous circulation. They were subdivided into 32-34 °C or 35-36 °C groups. The primary endpoint was an adjusted predicted probability of 30-day favorable neurological outcome, defined as a cerebral performance category score of 1 or 2.

Result: Of 435 patients, 139 had mild, 182 had moderate, and 114 had severe hyperlactatemia. One hundred and eight (78%) with mild, 128 with moderate (70%), and 83 with severe hyperlactatemia (73%) received TTM at 32-34 °C. The adjusted predicted probability of a 30-day favorable neurological outcome following severe hyperlactatemia was significantly greater with 32-34 °C (27.4%, 95% confidence interval: 22.0-32.8%) than 35-36 °C (12.4%, 95% CI 3.5-21.2%; p = 0.005). The differences in outcomes in those with mild and moderate hyperlactatemia were not significant.

Conclusions: In OHCA patients with severe hyperlactatemia, the adjusted predicted probability of 30-day favorable neurological outcome was greater with TTM at 32-34 °C than with TTM at 35-36 °C. Further evaluation is needed to determine whether TTM at 32-34 °C can improve neurological outcomes in patients with severe hyperlactatemia after out-of-hospital cardiac arrest.