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

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

  1. 1. BEFORE
  2. 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. 3. Learning Objective  Describe the clinical indications and dosing recommendations of magnesium for patients undergoing therapeutic hypothermia
  4. 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. 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. 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. 7. Complications of TH  Shivering  Hemodynamic instability  Glycemic control  Electrolyte imbalances  Coagulopathy  Infection
  8. 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. 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. 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. 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. 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. 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. 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. 15. AFTER
  16. 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. 17. Learning Objective Describe the indications and dosing recommendations of magnesium for patients undergoing therapeutic hypothermia
  18. 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. 19. Pain Sedation Paralytics
  20. 20. Mechanism Thermoregulation Reduced shivering Neuroprotection
  21. 21. Reduced shivering threshold Increased comfort No affect on gain of shivering
  22. 22. Vasodilation Faster time to TTM Higher comfort score Heart rate
  23. 23. Benefits NMBA-Sparing? Role

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