Chicago 2014 TFQO: Clifton Callaway # EVREV 1: Janice Zimmerman # EVREV 2: Jonathan Sullivan COI # Taskforce: ALS ALS 790 : Induced Hypothermia

Chicago 2014 COI Disclosure (SPECIFIC to this systematic review) Janice Zimmerman COI# Commercial/industry List here Potential intellectual conflicts List here Jonathan Sullivan COI# Commercial/industry List here Potential intellectual conflicts List here

Chicago TR Strategies to treat hyperglycemia (>180 mg /dL) should be considered in adult patients with sustained ROSC after cardiac arrest. Hypoglycaemia should be avoided.

Chicago 2014 C2015 PICO Population: patients with ROSC after cardiac arrest in any setting Intervention: A specific range for blood glucose management (e.g. strict 4-6 mmol/L) Comparison: compared with any other target range Outcomes: Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year (9-Critical) Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year (8-Critical)

Chicago 2014 Inclusion/Exclusion & Articles Found We did not include studies without a concurrent comparator group or studies that only reported associations between glucose and outcome but did not treat patients differently. The search yielded a total of 451 studies. Of these, one RCT and one observational studies were included for bias assessment. Oksanen et al Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med; 33 (12): Sunde et al Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation; 73 (1):

Chicago 2014 Draft Treatment Recommendations We suggest not selecting any specific target range of glucose management versus any other target range in adults with ROSC after cardiac arrest (weak recommendation, moderate quality of evidence). In making this recommendation, we noted that strict glycemic control is labor intensive. In other populations, implementation of strict glycemic control is associated with increased episode of hypoglycemia, which might be detrimental. There are no data that the approach to glucose management chosen for other critical care populations should be modified for the cardiac arrest population.

Chicago 2014 Risk of Bias in RCTs

Chicago 2014 Risk of Bias in non-RCTs

Chicago 2014 Evidence profile table(s)

Chicago 2014

Proposed Consensus on Science statements For the critical outcome of survival to hospital discharge, one RCT of 90 subjects, downgraded for risk of bias, found no reduction in 30-day mortality (RR 0.94; 95%CI ) when subjects were assigned to strict (4- 6mmol/L) versus moderate (6-8 mmol/L) glucose control (Oksanen 2007). For the critical outcome of survival to hospital discharge, one before-and-after observational study of 119 subjects found reduced in-hospital mortality (RR 0.46; 95%CI ) after implementation of a bundle of care that included defined glucose management (5-8 mmil/L), but the isolated effect of glucose management is confounded by and cannot be separated from the effect of other parts of the bundle (Sunde 2007).

Chicago 2014 Draft Treatment Recommendations We suggest not selecting any specific target range of glucose management versus any other target range in adults with ROSC after cardiac arrest (weak recommendation, moderate quality of evidence). In making this recommendation, we noted that strict glycemic control is labor intensive. In other populations, implementation of strict glycemic control is associated with increased episode of hypoglycemia, which might be detrimental. There are no data that the approach to glucose management chosen for other critical care populations should be modified for the cardiac arrest population.

Chicago 2014 Knowledge Gaps *DO NOT USE FOR PLENARY* - BREAKOUT ONLY When neurologic assessors are independent of the clinical teams (main weakness from the Bernard et al. and HACA trials), is targeted temperature management better than no targeted temperature management?