Therapeutic Hypothermia to Improve Outcomes Post OHCA

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  • 1. Therapeutic Hypothermia to Improve Outcomes Post OHCA By: L. Bloxham, E. Foley, D. Price, & L. Pendergraft College of Nursing, University of Oklahoma - 2010
  • 2. PICO Question P opulation Adult survivors of cardiac arrest who have regained circulation but remain comatose I ntervention Therapeutic Hypothermia (32  to 34  C) C omparison Maintaining Normothermia (37  C) O utcome Reducing mortality and improving neurological outcomes
  • 3. PICO Question In adult survivors of primary cardiac arrest who have regained circulation but remain comatose, what is the effect of therapeutic hypothermia (32  to 34  C) on reducing mortality and improving neurological outcomes compared with maintaining normothermia (37  C) post-cardiac arrest?
  • 4. Definitions Adult 18-64 years old Normothermia 37  C Long Term Minimum of 1 year Cardiac Arrest Cardiac arrest is defined as cessation of cardiac mechanical activity and is confirmed by the absence of signs of circulation. American Heart Association (2009)
  • 5. Definitions Comatose A score ranging from 3-8 using the Glasgow Coma Scale ROSC Return of spontaneous circulation Therapeutic Hypothermia Patients cooled to a core temperature between 32  to 34  C for 12-24 hours Good Neurological Outcome Cerebral Performance Category (CPC) scores of one or two American Heart association (2009)
  • 6. Identification of the Problem
    • Every two to three minutes, someone in the United States goes into cardiac arrest. 
    • Out-of-Hospital cardiac arrest (OHCA) affects approximately 300,000 people in the United States annually, and survival is generally less than 10%. 
    • Approximately 10% to 30% of out-of-hospital cardiac arrest survivors have permanent brain injury as a result of global ischemia. 
    • National Heart, Lung and Blood Institute (2008)  Merchant, R.M., et al (2009)  Barht, G. (2009)
  • 7. Prevalence & Cost
    • Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States. *
    • Cardiac arrest cost Americans 2.2 billion dollars annually in direct cost. **
    • * Heart Rhythm Foundation (n.d.) ** Ambrose, R. (2004)
  • 8. Review of Literature Medical Research Systematic Review Randomized Control Trials Clinical Guidelines Retrospective Studies Observational Studies
  • 9. Review of Literature
    • Arrich, J., Holzer, M., Herkner, H., Müllner, M. (2009)
    • Systematic review & meta-analysis. Four trials and one abstract reporting on a total of 481 patients were included in the review.
    • Therapeutic Hypothermia (TH) improves survival and neurologic outcome in patients successfully resuscitated from cardiac arrest when they meet the following criteria: out-of-hospital cardiac arrest of cardiac cause with VF/VT as first recorded rhythm.
  • 10. Review of Literature
    • Bernard, S.A., et al. (2002)
    • Randomized control trial. A total of 77 patients were randomly assigned to hypothermia or normothermia group after successful resuscitation outside of hospital.
    • 49% of patients in the hypothermia group were considered to have a good outcome compared with 26% of the normothermia group.
  • 11. Review of Literature
    • Hypothermia After Cardiac Arrest Study Group. (2002)
    • Randomized control trial. A total of 275 patients enrolled in study. Included in the study were patients 18-75 years old that had a witnessed cardiac arrest, presumably or cardiac origin, with ventricular fibrillation or non-perfusing ventricular tachycardia as the initial rhythm.
    • Systematic cooling to 32°C-34°C for 24 hours increased the chance of survival and of a favorable neurological outcome (Cerebral performance scale category 1 or 2).
  • 12. Review of Literature
    • Nielsen, N., et al. (2009)
    • Observational study. A total of 986 out-of- hospital cardiac arrest patients treated with therapeutic hypothermia (TH), regardless of the cause of the cardiac arrest.
    • Neither timing of TH nor the duration were significantly associated with the outcome of the treatment.
    • After TH, 676 patients were alive (69%) of whom 401 (41%) had a good neurological outcome (CPC 1 or 2).
  • 13. Review of Literature
    • Oddo, M., et al. (2006)
    • Retrospective study. A total of 109 patients resuscitated from out of hospital cardiac arrest with initial rhythms of VF, asystole, or pulseless electrical activity (PEA). All were in a persistent coma at admission.
    • In patients with VF as the initial rhythm, 55.8% of patients treated with TH had a good outcome compared to 25.6% of patients treated with standard resuscitation (SR).
    • 60.5% of TH patients survived to discharge compared to 44.2% of SR patients.
  • 14. Therapeutic Hypothermia-Pros
    • Saves lives and improves quality of life for survivors.
    • Does not cause an increase in patients surviving in a persistent vegetative state.
    • Side effects are predictable and can be prevented or managed easily.
    • Cost effective and relatively easy to implement, the procedure lends itself well to a protocol.
  • 15. Therapeutic Hypothermia-Cons
    • Specific patient populations may encounter more side effects
    • Eligibility criteria too narrow
    • Unrealistic to have 1:1 patient/nurse ratio; as studies suggest close monitoring is required through cooling and re-warming phase. This could particularly be a problem when cooling is initiated in ER
    • Requires training, if not used often this may be a problem for units with high turnover
  • 16. Summary of Findings
    • Therapeutic hypothermia improves survival and neurologic outcome in patients successfully resuscitated from cardiac arrest.
    • Research concluded that therapeutic hypothermia is an acceptable investment of health care dollars whose benefits justify its costs.
    • Adverse events were not significantly greater in therapeutic hypothermia patients than in normothermia control groups.
  • 17. Internal Method 11sd
  • 18. External Method 11sd
  • 19.
    • Inclusion Criteria
    • Cardiac arrest in any patient location
    • TH initiated within 6 hours of ROSC
    • Comatose
    • 18 years of age and older
    Current Practice Hospital A: Protocol in place
    • Exclusion Criteria
    • Refractory Shock
    • Systolic BP<90 mm Hg despite fluids and pressors
    • Refractory Ventricular Arrhythmia
    • Coagulopathy or uncontrollable bleeding
    • Pregnancy
  • 20.
    • Inclusion Criteria
    • Cardiac arrest
    • TH initiated within 6 hours of ROSC
    • Comatose
    • 18-80 years of age
    • Exclusion Criteria
    • Intracranial hemorrhage
    • Trauma or terminal illness
    • Coagulopathy or uncontrollable bleeding
    • Pregnancy
    Current Practice Hospital B: Protocol in place
  • 21.
    • Inclusion Criteria
      • Non-Traumatic cardiac arrest with return of circulation
    • TH initiated within 6 hours of arrest
    • Systolic BP > 90 or MAP > 60 after fluid resuscitation with or without pressors
      • > 12 years old
    Current Practice Hospital C: Protocol in place
    • Exclusion Criteria
    • GCS > 8
    • Greater than 6 hours since arrest
    • DNR
    • Non-mechanically ventilated patient
    • Pregnancy
    • Active bleeding
    • Arrest secondary to sepsis
  • 22. Recommendations
    • For facilities not currently initiating therapeutic hypothermia :
    • Establish protocol to begin using therapeutic hypothermia.
    • Research has shown that therapeutic hypothermia is known to improve neurological outcomes and increase survival rates in out-of-hospital cardiac arrest.
  • 23. Recommendations
    • For facilities currently using therapeutic hypothermia:
    • Revisit inclusion criteria, as additional research is needed to ensure that all those that would benefit from therapeutic hypothermia are included.
    • Begin intervention in the ED/ER, as opposed to waiting until patient is transferred to the ICU.
  • 24. Evaluating Effectiveness
    • Evaluate hospital compliance
    • Direct observation
      • Chart reviews
    • Evaluate effectiveness
      • Awareness Campaign, Training, & Implementation
      • Patient outcomes
        • Retrospective studies
      • Cost effectiveness
  • 25. Suggestions for Further Study
    • More randomized controlled trials with wider eligibility requirements
    • Larger sample size for studies
    • Prospective studies to evaluate patient outcomes greater than one year post OHCA when induced hypothermia was implemented
    • Studies focused on where induced hypothermia should be implemented
  • 26. New Research Questions
    • Is broadening the inclusion criteria for patients to receive therapeutic hypothermia beneficial?
    • Is there a decreased length of stay as a result of therapeutic hypothermia?
    • Would initiating hypothermia in the ambulance on the way to the hospital further increase survival?
  • 27. Advanced life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III25-54. Ambrose, R. (2004). The Cost of cardiac arrest in the workplace. Occupational Health & Safety, Retrieved from http://ohsonline.com/Articles/2004/09/The-Cost-of-Cardiac-Arrest-in-the- Workplace.aspx?Page=2 American Heart Association. (2009). News releases: Cooling therapy for cardiac arrest survivors is as cost-effective as accepted treatments for other conditions. Retrieved from http://americanheart.mediaroom.com/index.php?s=43&item=795 . Arrich, J., Holzer, M., Herkner, H., Müllner, M. (2009). Hypothermia for Neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database of Systematic Reviews , 4, 1-33. References
  • 28. Barht, G. (2009). Cooler heart, better odds: induced hypothermia. Nursing Management, 40(7), Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=869342 Centers for Disease Control. (2009). Chronic disease prevention and health promotion: Heart disease and stroke prevention. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/AAG/dhdsp.htm Heart Rhythm Foundation, (n. d.). Sudden cardiac arrest statistics. Heart Rhythm Facts and Stats. Retrieved from http://www.heartrhythmfoundation.org/facts/scd.asp Merchant, R.M., Becker, L.B., Abella, B.S., Asch, D.A., Groeneveld, P.W. (2009). Cost-effectiveness of therapeutic hypothermia after cardiac arrest. Circulation: Cardiovascular Quality & Outcomes, 2(5), 421-28. National Heart, Lung and Blood Institute. (2008). National Institute of Health news: Automated external defibrillators and CPR are equally helpful for sudden cardiac arrest in the home. Retrieved from http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=256 . References