Patients were excluded if their initial esophageal temperature (Tes) was <34 °C or if they had a known coagulopathy, pregnancy and/or terminal disease, which did not allow any further intensive care escalation. Furthermore, patients with prehospital cooling who were cooled with invasive devices or i.v. cold fluids after admission were excluded from final analysis. After ROSC, temperature was measured by inserting an esophageal temperature probe (Mon-a-therm General Purpose, 12 Fr, Mallinckrodt Medical Inc., St. Louis, MO, USA) with placement guided by a tracheal tube. The temperature buy NU7441 probe was connected

to a monitoring device before initiating cooling. Cooling was performed by application of cooling pads29 (EMCOOLS Flex.Pad®, EMCOOLS – Emergency Medical Cooling Systems AG, Pfaffstätten, Austria) on the thorax, back, abdomen and thighs (Fig. 1). Time of cooling start and first AZD6244 order Tes measured prior to cooling was documented. These cooling pads consisted of multiple cooling cells filled with a cooling gel. The inner layer was a biocompatible film, which adhered to the patient’s skin on application and provided intimate pad to skin contact for efficient heat transfer. During the study period, 3 out of 18 ambulances

in the city were equipped with the cooling pad. Before use, the cooling pad was stored in a cooling box at approximately −9 °C in the ambulance. During transport in the ambulance, the cooling procedure was continued. After admission of patients in whom cooling had been initiated in the prehospital setting, Tes was again measured and monitored. The cooling pads were inspected by the attending physicians and nurses and exchanged if the cooling gel inside had already melted. The entire cooling

pad was removed when Tes reached 33.9 °C and due to the cold skin, the cooling down process continued to a certain Endonuclease extend. After reaching Tes of 33 °C, external cooling was continued for 24 h by using the cooling pad guided by an established protocol30: During maintenance cooling, two single cooling units were applied as needed to keep Tes between 33 °C and 33.5 °C. No additional cooling method was applied. After 24 h of maintenance cooling, patients were allowed to rewarm passively. During the entire process, sedation and anesthesia were given using the following protocol: sedation, analgesia and paralysis were initiated with a midazolam bolus of 5 mg, followed by continuous infusion (250 mg/50 mL midazolam, started at 0.125 mg/kg/h and adjusted as needed); a fentanyl bolus of 0.1 mg, followed by continuous infusion (2.5 mg/50 mL fentanyl, started at 0.002 μg/kg/h and adjusted as needed); and a rocuronium bolus of 0.5 mg/kg, followed by continuous infusion of 0.5 mg/kg/h.