Therapeutic hypothermia
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Therapeutic hypothermia

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Discussion of therapeutic hypothermia for cardiac arrest.

Discussion of therapeutic hypothermia for cardiac arrest.

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Therapeutic hypothermia Therapeutic hypothermia Presentation Transcript

  • Therapeutic HypothermiaFrank W Meissner MD, FACP, FACC, FCCP, FASNC
  • The Hidden Obstacle to Reanimation CNS Reperfusion Injury Simply defined as ‘damage observed after resoration of blood flow to ischemic tissues’
  • Hypoxic Cerebral Insult6% Decrease in Cerebral Metabolism per1°C Decrease Core Body Temp => Anti-inflammatory EffectsResultant Suppression Of CNS ReperfusionInjury Decreased Free Radical Production Reduced Excitatory Neurotransmitters Suppression of Ca++ mediated cell death
  • Proof of Theory Studies
  • HACA* Study GroupWitnessed Cardiac Arrest (VF ^ VT) Age 18-75 yr Est time Reanimation attempt 5-15 min ROSC ≤ 60 mins275 of 3,551 Arrests Met Inclusion Criteria137 Randomized to Hypothermia Body Core Temperature 32-34° C X 24 hr Rewarmed over 8 hr * Hypothermia After Cardiac Arrest
  • Principle Results I Cumulative Survival in the Normothermia and Hypothermia GroupsThe Hypothermia after Cardiac Arrest Study Group, . N Engl J Med 2002;346:549-556
  • Principle Results IIThe Hypothermia after Cardiac Arrest Study Group, . N Engl J Med 2002;346:549-556
  • Current AHA (Y2005) GuidelineUnconscious adult patients with ROSC afterout-of-hospital arrest cooled to 32 - 34 °C(89.6 - 93.2° F) X 12-24 hr in V FibArrest(Class IIa)Similiar therapy may be beneficial for out-ofhospital or in-hospital non-VF arrest (ClassIIb)
  • Optimal Therapy
  • Surface Cooling I Conventional Surface Cooling (circulating cold water blankets or cold air-forced blankets) can take 4-8 hrs toreach 32-34° and temperature titration can be difficult CritiCool System uses 3-D CureWrap™ one piece garment with temperature controller resulting in high efficiency precisely controlled external cooling
  • Surface Cooling IIAdvantages Application in 2 minutes Portable no power requirements High Cooling Capacity Radioluminescent User friendly Suitable for induction and maintenance of cooling Low investment costs
  • Medivance Arctic Sun™Patented DesignArctic Sun andArcticGel™ Padsenables transfer ofup to five timesmore thermalenergy thanconventionalmethods such aswater blankets,wraps or ice packs.System’s precisionenables slowrewarming thoughtto be critical fortherapeutic benefit. The Arctic Sun hasreceived 510(k) FDAclearance in theU.S.
  • Blanketrol™ III
  • Invasive Cooling Methods I 30ml/kg Lacated Ringers Solution @ 4° C infused via femoral catheter over 30 mins => T 35.5 to 33.8° C Rapid & predictable + volume infusion blunts hypothermia induced diuresis Maintenance therapy cooling blanketsBernard, S. et al. Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: A preliminary report. Resuscitation 2003;56:9-13)
  • Invasive Cooling Methods IIShivering bluntsexternal coolingefforts unlessmoderated byPropofol orBenzo’s Zoll (Formerly Alsius) Thermogard XP System
  • Thermal Regulatory Performance Cincinnati Medeco Icy Catheter Arctic Sun Subzero Conventional Caircooler Blanketrol III External H20 Cooling IV Heat External Gel- External Air Cold Saline, Ice, Circulating Circulating Pads Method Exchange coated Pads bags, Etc. Pads Cooling Rate (°C) 1.46 1.04 1.33 0.18 0.32 % of time Temp out of range (>0.2 °C from 3.2 44.2 50.5 74.1 69.8 Target Temp) Hoedemaekers CW, et al. Comparison of different cooling methods to induce and maintain normo- and hypothermia in ICU patients: a prospective intervention study. Critical Care 2007; 11:R91.
  • Invasive Cooling III Zoll Catheter Systems
  • Invasive Cooling IVZoll Catheter Systems
  • Practical ApproachInduction Phase (within 4 hr of arrest) Cold IV Saline NG Iced Lavage Cold Packs in Groin & AxillaMaintenance Phase (12 to 24 hr) IV Cooling Catheter External Cooling Patches or Arctic Sun SystemRewarming Phase (Precise Temp Control VITAL) 0.25 - 0.5 ° C/hr
  • Financial Analysis Avg Avg Direct Avg Direct Revenue Margin Per Cost Per Pt Per Pt PtDischarged $57,783 $37,099 $20,684 AliveExpired in $12,014 $8,686 $3,329 Hospital Take Heart America Program St Cloud Minn - Dec 05- Nov 07
  • Financial AnalysisOn average, each SCA patient deliveredalive to ED generated $27,900 ofrevenue & $9,400 of direct marginregardless of outcome in the hospital
  • Financial AnalysisSt Cloud saw a 131% increase in arrestsurvival rate compared to previous year=> $1,088,000 additional hospitalrevenue with direct margin of $366,000over 19 month period of the study
  • Knowledge TransitionHACA Theory Into Practice Europe & USA 30-40%Implementation of therapeutic hypothermiaguidelines for post-cardiac arrest syndrome at aglacial pace: Seeking guidance from theknowledge translation literatureResuscitation - Volume 77, Issue 3,Pages 286-292 (June 2008)
  • Barrier’s To Implementation500% variation in post arrest survivalTherapeutic Nihilism & FatalismStove-piped ProcessesInability To Effectively TeamLack of Physician ChampionInstitutional Financial Concerns
  • Level I Cardiac Arrest Center Minimum of 40 reanimated patient’s annually Aligned with STEMI Primary PCI Treatment of re-arrest EP assessment and/or ICD assessment and implantation
  • Roadmap