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ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)
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ITC Slide Redesign Competition: Runner-Up (Nadia Awad, PharmD)

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The April 2014 International Teaching Course held a Slide Redesign Competition, hosted by Dr. Stacey Poznanski

The April 2014 International Teaching Course held a Slide Redesign Competition, hosted by Dr. Stacey Poznanski

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  • 1. BEFORE
  • 2. Don’t Give Mag the Cold Shoulder: The Role of Magnesium in Therapeutic Hypothermia Nadia Awad, Pharm.D. Clinical Assistant Professor, Emergency Medicine Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey
  • 3. Learning Objective  Describe the clinical indications and dosing recommendations of magnesium for patients undergoing therapeutic hypothermia
  • 4. Clinical Vignette  TM is a 54-year-old male who is brought in to your emergency department after experiencing a cardiac arrest at home  Both the paramedics and the emergency medicine physicians confirm ventricular fibrillation on the cardiac monitor  With multiple rounds of resuscitation, return of spontaneous circulation (ROSC) is achieved  The decision is made to initiate therapeutic hypothermia
  • 5. The Basics  Therapeutic hypothermia (TH): • Induction of hypothermia in patients following cardiac arrest or traumatic brain injury to reserve neurological function • Benefits: • Delays the progression of inflammatory cascade • Reversal and/or prevention of cerebral ischemia by improving oxygen supply-demand mismatch
  • 6. The Phases of TH 0 4 8 12 16 20 24 28 32 36 40 44 48 38 37 36 35 34 33 32 31 Degrees(Celsius) Hours from Initiation of TH Initiation of Cooling Maintenance Rewarming Normothermia Critical role of the EM Pharmacist
  • 7. Complications of TH  Shivering  Hemodynamic instability  Glycemic control  Electrolyte imbalances  Coagulopathy  Infection
  • 8. “Shiver Me Timbers!”  Shivering in TH: • Autonomic response to counter the effects of hypothermia • Occurs more commonly at temperatures between 35 and 37°C • With resultant heat generation and potential hyperthermia: • Delays in achievement of core body temperature • Increased metabolic rate • Increased oxygen demand
  • 9. Typical Treatment Strategies for Shivering  Sedation and analgesia: • Mitigation of shivering • Results in vasodilation to expedite surface cooling  Preferential for use of agents with short half-lives  If persistent, use of neuromuscular blockade agents (NMBAs) • Intermittent bolus administration of non-depolarizing NMBAs
  • 10. Magnesium for Shivering: Say What??  Mechanism: • N-methyl D-aspartate (NMDA) receptor antagonist  Manifestation of effects: • Facilitates thermoregulation to nonadrenergic and serotonergic neurons to counter the effects of hyperthermia • Reduces post-anesthetic shivering • May offer neuroprotection through cerebral vasodilation due to effects on smooth muscle tone Altura et al. Magnesium 1984; 3:195-211. Kizilirmak et al. Ann N Y Acad Sci 1997; 813:799-806. Schmid-Elsaesser et al. Stroke 1999; 30:1891-1899. Lysakowsky et al. Anesth Analg 2007; 104:1532-1539.
  • 11. The Proof is in the Evidence  Experimental study (N = 9) • Healthy volunteers • Invasive cooling via infusion of lactated Ringer’s solution  Intervention: • Control: normal saline • Magnesium: 80 mg/kg IV bolus followed by infusion of 2 g/hr  Results: • Reduction in shivering threshold (p = 0.04) • Increase in shivering comfort (p = 0.019) • No difference in gain of shivering response (p = 0.344) Wadhwa et al. Br J Anaesth 2005; 94:756-762.
  • 12. The Proof is in the Evidence…Again  Experimental study (N = 22) • Healthy volunteers  Active cooling via surface cooling technique for a maximum of 5 hours  Randomized to receive one of four interventions: 1) Meperidine 50 to 100 mg IV (n = 5) 2) Meperidine plus buspirone, 30 to 60 mg PO (n = 4) 3) Meperidine and ondansetron, 8 to 16 mg IV (n = 5) 4) Meperidine, ondansetron, and magnesium sulfate, 4 to 6 g IV bolus followed by 1 to 3 g per hour infusion (n =8) Zweifler et al. Stroke 2004; 35:2331-2334.
  • 13. The Proof is in the Evidence…Again  Results: • Achievement of vasodilation greater in those who received magnesium than other interventions • 88% (7 of 8) versus 29% (4 of 14) (p = 0.024) • Shorter time in achievement of target tympanic temperature of 35°C (p = 0.039) • Higher comfort scores in magnesium group (p < 0.01) • No significant differences in SBP, DBP, MAP, or oxygen saturation • Some significant decreases in HR Zweifler et al. Stroke 2004; 35:2331-2334.
  • 14. Take Home Message  Magnesium can provide some benefit in patients undergoing TH • Reduces shivering threshold • Improved patient comfort  A bolus dose of 4 g of intravenous magnesium sulfate can be reasonably and safely administered for such patients  Can be considered as an adjunctive treatment for refractory shivering in TH that does not improve with standard therapies
  • 15. AFTER
  • 16. Don’t Give Mag the Cold Shoulder: The Role of Magnesium in Therapeutic Hypothermia Nadia Awad, Pharm.D., BCPS Clinical Assistant Professor, Emergency Medicine Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey
  • 17. Learning Objective Describe the indications and dosing recommendations of magnesium for patients undergoing therapeutic hypothermia
  • 18. Phases of TH 0 4 8 12 16 20 24 28 32 36 40 44 48 38 37 36 35 34 33 32 31 Degrees(Celsius) Hours from Initiation Critical Role of the EM Pharmacist
  • 19. Pain Sedation Paralytics
  • 20. Mechanism Thermoregulation Reduced shivering Neuroprotection
  • 21. Reduced shivering threshold Increased comfort No affect on gain of shivering
  • 22. Vasodilation Faster time to TTM Higher comfort score Heart rate
  • 23. Benefits NMBA-Sparing? Role

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