Therapeutic Hypothermia in France not been assessed in France, a national survey was aimed at evaluating the management of this treatment in French intensive care units (ICUs). Concerning both the targeted temperature and the duration of hypothermia, 112 ICUs (92% [87–97%]) followed both ERC recommendations. Materials and Methods Our institutional review board (Comite´ de protection des personnes Sud Me´diterrane´e V) has waived the need for ethical approval for this study. Addresses of all registered French intensive care units (n = 357) were obtained from the national health facilities website. Paediatrics and neurosurgery ICUs were excluded of the study. A structured evaluation questionnaire was sent to the heads of the ICU (medical or surgical intensivist) by e- mail starting October 2010 to May 2011 (see Questionnaire S1). The survey addressed structure of the hospitals, number of admissions for cardiac arrest in 2009, indications for the use of therapeutic hypothermia after cardiac arrest, cooling methods employed, sedation practices and prognostic factors used (see additional material). When no response was received after 2 reminders, ICUs clinical managers were contacted by phone to increase the rate of responses. Data collection ended in June 2011. Quantitative and qualitative data are expressed in median value with interquartile range (IQR) and in frequency with percentage (%) with the 95% confidence interval. Results One hundred and thirty two questionnaires were returned (response rate = 37% [32–42%]), mainly from non-academic institutions (n = 81, 61%). Six units declared not using therapeutic hypothermia, leaving 126 units for final analysis of these de- clarative data. Indication of hypothermia: Therapeutic hypothermia was induced after out of hospital cardiac arrest due to ventricular fibrillation in 119 ICUs (99% [97–101%]) and after asystole in 111 ICUs (93% [88–98%]). Method of Cooling External, internal and mixed methods were applied in 54% [45–63%], 20% [13–27%] and 26% [19–35%] ICUs, respective- ly. The main reasons for this choice were the easiness of applicability (64% [55–73%]) and the cost effectiveness (48% [39–57%]). The time to reach the target temperature was assessed as ,6 hours in 92 ICUs (75% [67–83%]). Temperature was monitored by oesophageal (49% [40–58%]) or bladder catheter probes (40% [31–49%]), thermometer (11% [5–17%]), skin and rectal probes (21% [14–28%]). Target temperature and duration of hypothermia (figures 1 and 2): The targeted temperatures were 33uC (58% [49–67%]), 34uC (23% [16–30%]) and 32uC (8% [3–13%]). Less frequently, the units chose a range of temperature between 32 and 34uC (6% [2– 10%]), and between 33 and 34uC (3% [0–6%]). Overall, the ERC recommendations regarding the targeted temperature (32 to 34uC) were followed in 118 ICUs (98% [96–100%]). Few units were outside the recommended temperature range: between 34 and 35uC (n = 2, 2% [0–4%]) and less than 35uC (n = 1, 1% [21– 3%]). The planned duration of therapeutic hypothermia was 24 hours in 101 ICUs (84% [77–91%]), 12 h in 7 ICUs (6% [2– 10%]), 12 to 24 h in 4 ICUs (3% [0–6%]) and 18 h in 2 ICUs (2% [0–4%]), leading to an implementation of the ERC recommenda- tions in 114 units (94% [90–98%]). The remaining expressed durations of hypothermia were 48 h (n = 5, 4% [0–8%]), 36 hours (n = 1, 1% [21–3%]) and 6 to 12 h (n = 1, 1% [21–3%]). Sedation during Therapeutic Hypothermia During therapeutic hypothermia, patients were given sedative drugs in 99% [97–101%] of ICUs. Midazolam (77% [70–84%]) and propofol (10% [5–15%]) were the hypnotic drugs used in first line. Sufentanil (59% [50–68%]), fentanyl (25% [17–33%]) or remifentanil (11% [6–16%]) were the most used analgesic drugs. Neuromuscular blocking agents were given during therapeutic hypothermia in 97% [94–100%] of units, mainly cisatracurium (77% [70–84%]) and atracurium (16% [10–22%]). Prognostic Factors One hundred and twenty ICUs (95% [91–99%]) reported the utilisation of one or more clinical prognostic factors such as absence of brainstem reflexes (90% [85–95%]), duration of cardiopulmonary resuscitation (85% [79–91%]), fixed dilated pupils (75% [67–83%]), seizures (73% [65–81%]) and the Glasgow Coma Scale (3% [0–6%]). Sixty-seven units (53% [44– 62%]) used biological prognostic factors, mainly lactate (55% [43– 67%]) and Neuron Specific Enolase (31% [20–42%]). The use of a combination of several biomarkers was reported in 13% [5– 21%] of ICUs. Evoked potentials were used in 44 ICUs, somesthetic in 77% [65–89%] and auditory in 23% [11–35%]. Ninety-eight ICUs reported the use of electroencephalography; flat trace (87% [80–94%]) and burst suppression pattern (58% [48–68%]) were the most frequent prognostic factors. Withdrawal of life sustaining treatments was considered in 98% [96–100%] of ICUs. Discussion In this declarative survey involving 126/353 of French ICUs, therapeutic hypothermia was induced after out of hospital cardiac arrest due to ventricular fibrillation and after asystole in 99% and 93% of ICUs respectively. The European Resuscitation Council recommendations regarding the target and the duration of therapeutic hypothermia were followed in 98% and 94% ICUs. Adherence to these two major objectives was 92% ICUs. Sedative and neuromuscular blocking drugs were given in 99% and 97% ICUs, respectively. Clinical, biological and electroencephalo- graphic prognostic factors were searched in 95%, 53% and 78% ICUs respectively. In our study, the percentage of compliance to recommendations regarding target temperature and hypothermia duration is higher compared to the figures reported previously in the United- Kingdom (63% for temperature and 72% for duration) [12]. Compliance to the 2 major recommendations is similar to the 83% previously reported in Italy [14]. Moreover, the rate of implementation of ERC guidelines is higher than those reported for the application of other recommendations such as protective ventilation during acute lung injury (50%) and initial management of severe sepsis and/or septic shock [15,16]. This difference could be explained by an easier identification of cardiac arrest patients. Furthermore, the ERC recommendations are not numerous and could be easily performed. Indeed, as several barriers could explain the poor implementation of guidelines, providing precise and simple recommendation is likely to facilitate their implemen- tation by physicians [17]. The range of recommended temperature is broad and the most efficacious target is still unknown. A more precise targeted temperature could be associated with different efficacy and PLOS ONE | www.plosone.org 2 September 2012 | Volume 7 | Issue 9 | e45284