Mild Therapeutic Resuscitative Hypothermia Edward M. Omron MD, MPH Critical Care Service
Introduction <ul><li>Improving outcomes from sudden cardiac death is a healthcare and only 0-30% survive to discharge. </l...
How does cooling work? <ul><li>During cardiac arrest maintenance of cerebral perfusion and oxygen delivery is critical to ...
Clinical Studies <ul><li>Two prospective, randomized clinical trials published in 2002, compared mild hypothermia (32 –24 ...
How to Cool <ul><li>Different cooling techniques are combined for optimal patient cooling.  </li></ul><ul><li>Induction co...
Timing and Depth of Cooling <ul><li>Cooling should be initiated after return of spontaneous circulation. The 2005 AHA ACLS...
Cooling Monitoring   <ul><li>Shivering which prevents achieving the target temperature is treated aggressively with paraly...
Rewarming <ul><li>After 18 hrs, begin warming the patient.  </li></ul><ul><li>Set the cooling machine for a desired body t...
Physiological Effects of Cooling
 
 
When a patient is cooled, pCO2, pO2 decrease, and pH increases, measured at the patient’s temperature. At 37ºC in Machine:...
Complications of Cooling <ul><li>Hypovolemia (hypothermia induced diuresis) </li></ul><ul><li>Coagulopathy (impaired coagu...
As you cool the patient, vasoconstriction will decrease effective vascular volume. -  Diuresis - Lose potassium - Lose pho...
Case Review <ul><li>65 yo wm presented to IRMC s/p  cardiact arrest secondary to ventricular fibrillation with return of s...
<ul><li>Vital Signs and Labs </li></ul><ul><ul><li>BP 122/72, HR 91, Temp 99 F, RR 26, Sat 99% </li></ul></ul><ul><ul><li>...
Hospital Course <ul><li>Hypothermia protocol initiated with cold saline and Blanketrol III set to 93 F </li></ul><ul><li>C...
Hospital Course <ul><li>First 6 hours  </li></ul><ul><ul><li>K = 2.8, repleted </li></ul></ul><ul><ul><li>P = 1.8 repleate...
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Mild therapeutic resuscitative hypothermia

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Introduction to therapeutic hypothermia for cardiopulmonary arrest after admission to the ICU
Edward Omron MD, MPH, FCCP
Pulmonary and Critical Care Medicine
Morgan Hill, CA 95037

Published in: Health & Medicine
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Mild therapeutic resuscitative hypothermia

  1. 1. Mild Therapeutic Resuscitative Hypothermia Edward M. Omron MD, MPH Critical Care Service
  2. 2. Introduction <ul><li>Improving outcomes from sudden cardiac death is a healthcare and only 0-30% survive to discharge. </li></ul><ul><li>Mild resuscitative therapeutic hypothermia with basic neuro-critical care interventions may improve neurologic outcomes in survivors of cardiac arrest. </li></ul><ul><li>Basic neuro-critical care interventions </li></ul><ul><ul><li>Airway Protection (Intubation and Mechanical Ventilation) </li></ul></ul><ul><ul><li>MAP >70 Hg or Cerebral Perfusion Pressure > 60 mm Hg </li></ul></ul><ul><ul><li>Treatment of cerebral edema if present </li></ul></ul><ul><ul><li>PCO2 arterial 30-35 mm Hg (not hyperventilation) </li></ul></ul><ul><ul><li>GI and DVT prophylaxis </li></ul></ul><ul><ul><li>Treatment of hyperglycemia (Glucose > 150 mg/dL) </li></ul></ul><ul><ul><li>Head of Bed to 30 degrees at all times </li></ul></ul>
  3. 3. How does cooling work? <ul><li>During cardiac arrest maintenance of cerebral perfusion and oxygen delivery is critical to neurologic outcome. </li></ul><ul><li>Hypothermia influences the entire cascade of destruction from ischemia, reperfusion injury, and cerebral edema </li></ul><ul><li>reduction in cerebral metabolism </li></ul><ul><li>reduction in vascular permeability and cerebral edema </li></ul><ul><li>reduction in immune response and inflammation </li></ul>
  4. 4. Clinical Studies <ul><li>Two prospective, randomized clinical trials published in 2002, compared mild hypothermia (32 –24 Celsius) with normothermia in comatose survivors of out of hospital cardiac arrest. </li></ul><ul><li>Both studies demonstrated a decreased likelihood of death and improved neurologic recovery with hypothermia and basic neuro-critical care interventions. </li></ul>
  5. 5. How to Cool <ul><li>Different cooling techniques are combined for optimal patient cooling. </li></ul><ul><li>Induction cooling is accomplished initially with ice-chilled crystalloid infusion and ice packs followed by a cooling blanket system. </li></ul><ul><li>Endovascular Cooling with Surface Cooling: </li></ul><ul><ul><li>Initially, 10 – 30 ml/kg ice-cold (4 degrees Celsius) crystalloid solutions (Lactated Ringer’s or Normal Saline) over 30 minutes </li></ul></ul><ul><ul><li>Cooling apparatus (Blanketrol III) with the water temperature set to 93 degrees Fahrenheit (33 degrees Celsius). </li></ul></ul>
  6. 6. Timing and Depth of Cooling <ul><li>Cooling should be initiated after return of spontaneous circulation. The 2005 AHA ACLS guidelines recommend cooling patients to 32-34 Celsius for 12- 24 hours. </li></ul><ul><li>Place rectal, esophogeal probe or Foley catheter thermistor in the patient and connect to machine. </li></ul><ul><li>Desired core temperature is 93 degrees Fahrenheit (33 – 33.5 degrees Celsius) within 4 hrs of presentation to the intensive care unit (goal is within 2 hrs). </li></ul><ul><li>Maintain a core temperature of 93 degrees Fahrenheit (33 – 33.5 degrees Celsius) for 18 hrs. </li></ul>
  7. 7. Cooling Monitoring <ul><li>Shivering which prevents achieving the target temperature is treated aggressively with paralytics and or demerol. </li></ul><ul><li>Mechanically ventilated patients are deeply sedated. </li></ul><ul><li>Midazolam (Versed) drip (0.5 mg/ml) 50 mg/100 ml NS -Initiate at 1 – 2 mg/hr </li></ul><ul><li>Fentanyl drip (5 mcg/ml) 500 mg/100 ml NS -Initiate at 0.5 mcg/kg/hr. </li></ul><ul><li>Atracurium (Tracrium) 0.3 – 0.5 mg/kg IVP as loading dose, followed by 8 – 14 mcg/kg/min continuous infusion with both Train of Four and BiSpectral Index (BIS) Monitoring options. </li></ul><ul><ul><li>Train of 4 titrate 0 to 1 and BiSpectral Index < 60 </li></ul></ul>
  8. 8. Rewarming <ul><li>After 18 hrs, begin warming the patient. </li></ul><ul><li>Set the cooling machine for a desired body temperature of 98.5 degrees Fahrenheit (37.5 degrees Celsius) with desired rate for warming at < 0.5 degrees/hr. </li></ul><ul><li>DO NOT ALLOW THE PATIENT TO SHIVER . Rebound hyperthermia is common and must be avoided. </li></ul>
  9. 9. Physiological Effects of Cooling
  10. 12. When a patient is cooled, pCO2, pO2 decrease, and pH increases, measured at the patient’s temperature. At 37ºC in Machine: 7.35 / 45 / 100 At 33ºC in Patient: 7.41 / 40 / 90 Blood Gases and Temperature
  11. 13. Complications of Cooling <ul><li>Hypovolemia (hypothermia induced diuresis) </li></ul><ul><li>Coagulopathy (impaired coagulation cascade and thrombocytopenia) </li></ul><ul><li>Electrolyte disorders (hypothermia induced diuresis, K, Mg, Ca) </li></ul><ul><li>Insulin resistance </li></ul><ul><li>Changes in drugs effects and metabolism (altered clearance of fentanyl, midazolam, and atracurium) </li></ul>
  12. 14. As you cool the patient, vasoconstriction will decrease effective vascular volume. - Diuresis - Lose potassium - Lose phosphate - Potassium shifts intracellularly As you warm up, patient intravascular space expands, and potassium shifts out of cells Danger of hyperkalemia if you replaced potassium earlier (Abiki 2001; CCM 29: 1726-30; Zeiner 2004; Resuscitation 60: 253-61) Electrolyte and Fluid Shifts
  13. 15. Case Review <ul><li>65 yo wm presented to IRMC s/p cardiact arrest secondary to ventricular fibrillation with return of spontaneous circulation within 60 minutes </li></ul><ul><ul><li>GCS on admission E1, M1, V1 = 3T </li></ul></ul><ul><ul><li>PMH: St. Jude Aortic Valve for AS, CAD, EF 25% </li></ul></ul><ul><ul><li>Meds: Coumadin, Furosemide, monopril </li></ul></ul>
  14. 16. <ul><li>Vital Signs and Labs </li></ul><ul><ul><li>BP 122/72, HR 91, Temp 99 F, RR 26, Sat 99% </li></ul></ul><ul><ul><li>Vent Settings: PRVC TV 600 , Peep 0, FIO2 = 100%, set rate 14 </li></ul></ul><ul><ul><li>ABG: 7.47, 27, 484, 19.5 </li></ul></ul><ul><ul><li>Na 139, K 4, BUN 16, Creat 0.9 </li></ul></ul><ul><ul><li>INR 3.7 </li></ul></ul><ul><ul><li>WBC 9, Hematocrit 41 </li></ul></ul><ul><ul><li>Troponin and CPK 2000 </li></ul></ul>
  15. 17. Hospital Course <ul><li>Hypothermia protocol initiated with cold saline and Blanketrol III set to 93 F </li></ul><ul><li>Clinical assessment initially revealed hypovolemia: crystalloid volume loading </li></ul><ul><ul><li>MAP >70 mm HG (presumed increased ICP) </li></ul></ul><ul><li>ABG at 4 hours </li></ul><ul><ul><li>pH = 7.255, PCO2 59.4, PaO2 278 </li></ul></ul><ul><ul><li>Could not correct respiratory acidosis till paralysis initiated, train of four 0 to 1 and bispectral to 40 </li></ul></ul>
  16. 18. Hospital Course <ul><li>First 6 hours </li></ul><ul><ul><li>K = 2.8, repleted </li></ul></ul><ul><ul><li>P = 1.8 repleated </li></ul></ul><ul><ul><li>Lactic acid = 2 </li></ul></ul><ul><ul><li>INR > 5, corrected with FFP </li></ul></ul><ul><ul><li>WBC decreased to 2.7 </li></ul></ul><ul><li>After 24 hours </li></ul><ul><ul><li>CT Head, No Acute Intracranial Process </li></ul></ul><ul><ul><li>Paralysis stopped with slow neurologic recovery </li></ul></ul><ul><ul><li>Retroperitoneal Bleed recognized and treated </li></ul></ul>
  17. 19. Questions?

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