Therapeutic hypo thermia


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Therapeutic hypo thermia

  1. 1. Therapeu(c  Hypothermia   1/8/13   Therapeutic Hypothermia Rules and Roles for Therapeutic Hypothermia Nice Ice Baby! B.McLean, MN, RN, CCRN, CCNS, NP-BC, FCCM 404-626-2843 What? Cardiac Arrest •  Out-of-hospital cardiac arrest (OOHCA) •  295,000 people annually in the US •  7.9% median survival rate •  Anoxic encephalopathy and neurologic deficits •  Therapeutic hypothermia (TH) clinical trials •  ILCOR recommendation for TH after resuscitation Lloyd-­‐Jones  D,  Adams  R,  Carnethon  M  et  al.  Heart  disease  and  stroke  sta(s(cs-­‐2009  update.  Circula(on  2009;119:e21-­‐e181.  
  2. 2. Therapeu(c  Hypothermia   1/8/13   Therapeutic Hypothermia •  Sudden Cardiac Death –  Estimated number of out-of-hospital SCD cases is 300,000 per yr in US –  Incidence anywhere from 35-125/100,000 people with 25% less than 65y/o –  Cobb JAMA 2002, de Vreede-Swagemakers JACC 1997 –  If ROSC and admitted, median survival to discharge in US is 7.9% •  Lloyd-Jones Circulation 2009 –  Favorable outcomes of those admitted to hospital is 11-48% indicating large number of pts who either die or have permanent severe neurological damage •  Becker Ann Emer Med 1993 The return of circulation should help, right? •  The cerebral microcirculation is disrupted by cell breakdown products. Sorry!!! The return of circulation initially brings cytotoxic substances released from cells elsewhere in the body resulting in a further cycle of destruction. What is it? •  Therapeutic hypothermia (TH) –  lower core temperature induced in patients to provide protection from neurologic damage due to ischemia. •  Used for various conditions such as acute myocardial infarction, acute cerebrovascular disease, acute lung injury, and acute spinal cord injury. •  TH improves –  oxygen supply to ischemic areas –  increases blood flow by decreasing oxygen consumption, glucose utilization, lactate concentration, intracranial pressure, heart rate, cardiac output, and plasma insulin levels.  
  3. 3. Therapeu(c  Hypothermia   1/8/13   The brain’s problem with cardiac arrest. •  Sudden global ischemia •  Energy supply ends •  Cellular metabolism ceases •  Without metabolism, •  Cells begin to deteriorate –  the point of no return is the fragmentation of nuclear DNA (apoptosis) •  Recent studies have revealed that TH is a useful method of neuroprotection against ischemic neuronal injury after cardiac arrest. Mechanisms hypothermia   ischemia   excitotoxicity   lower     glutamate   metabolic  rate   release    inflammatory   cascades     cell  death   less  oxygen   calcium  shiNs   consump(on   blood  brain  barrier   disrup(on  &   cerebral  edema   reperfusion   mitochondrial   dysfunc(on   oxygen-­‐free  radicals   Geocadin    RG,  Koenig  MA,  Jia  X  et  al.  Management  of  brain  injury  aNer  resuscita(on  from  cardiac  arrest.  Neurol  Clin.  2008;22:487-­‐506.  
  4. 4. Therapeu(c  Hypothermia   1/8/13   Summary: How does cooling work? •  During cardiac arrest maintenance of cerebral perfusion and oxygen delivery is critical to neurologic outcome. •  Hypothermia influences the entire cascade of destruction from ischemia, reperfusion injury, and cerebral edema –  reduction in cerebral metabolism –  reduction in vascular permeability and cerebral edema –  reduction in immune response and inflammation Cerebral Summary •  Reducing cerebral metabolism (approximately 6-8% per 1ºC) •  Reducing excitatory amino acids (glutamate release) •  Stabilizes blood brain barrier •  Stabilizes spinal circulation •  Reduces inflammation response •  Restores normal cellular function •  PROTECTS the brain from reperfusion Cardiac Summary •  Decrease The Area Of Injury •  Promote Epicardial Reflow •  Decrease Myocardial Metabolic Demand •  Preserve Intracellular High-energy Phosphate Stores •  PROTECTS The Heart From Energy Demands  
  5. 5. Therapeu(c  Hypothermia   1/8/13   Summary: How Does Cooling Work •  Therapeutic Hypothermia –  Reduces metabolism –  Protects cerebral cells from Ca++ (acts like acid) –  Promotes metabolic alkalosis (K+ into cells) –  Decreases immune response (WBC goes down) –  Reduces renal regulation (patient can urinate to death) –  Which then causes profound hypovolemia! (increasing HcT) –  Inhibits coagulation ( PT/INR increase) The Prime time Out-of Hospital VF arrest with ROSC •  2 randomised controlled trials •  European - within 4hrs, for 24hrs –  55% vs 39% favourable neurological outcome –  Mortality 41% vs 55% –  (included 10pts with IHA) •  Australian study –  pseudorandomised, maintain temp for 12hrs –  51%vs 26% favourable neurological outcome –  51 vs 68% mortality  
  6. 6. Therapeu(c  Hypothermia   1/8/13   Summary of Landmark Trials HACA Bernard (European) (Australian) Initial rhythm VF or VT VF Pre ED Cooling No Yes Target Temp 32 to 33 C 33 C Hypothermia patients 136 43 Standard Rx Patients 137 34 Hypothermia duration 24 hours 12 hours Morbidity Reduction ARR 16%, NNT 6 ARR 16%, NNT 4 Mortality Reduction ARR 14%, NNT 6 ARR 17%, NNT 6 Adverse events (sepsis, NS NS arrhythmias & Bleeding) RL   HACA  study  group,  NEJM,  2002  &  Bernard  SA,  NEJM  2002   Cool It Outcomes HACA Non-HACA criteria P All Patients criteria (PEA, asystole, Value (VT & VF) shock) Total 103 52 51 Number Survival at 58 (56%) 38 (73%) 20 (39%) 0.0007 Discharge HACA Study Outcomes Survival  and  Neurologic  Outcome  at  Discharge/six  months  a>er   Hypothermia Normothermia Survival 87/137 (64%) 69/138 (50%) Favorable neurologic 64/134 (47%) 42/135 (31%) outcome  
  7. 7. Therapeu(c  Hypothermia   1/8/13   The Prime time •  Summary of 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care regarding the use of hypothermia –  Unconscious adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34ºC for 12-24 hours when initial rhythm was ventricular fibrillation (VF) (class IIa). –  Similar therapy may be beneficial for patients with non-VF arrest out-of-hospital or with in-hospital arrest (class IIb). –  Hemodynamically stable patients with spontaneous mild hypothermia (>33ºC) after resuscitation from cardiac arrest should not be actively rewarmed. 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. All about the …….  
  8. 8. Therapeu(c  Hypothermia   1/8/13   Welcome to Prime Time Mild  hypothermia  is  the  only  therapy  applied   in  the  post–  cardiac  arrest  se]ng  that  has   been  shown  to  increase  survival  rates  and   neurological  outcomes.   Source   ILCOR  Consensus  Statement.  (2008).   Post–Cardiac  Arrest  Syndrome.   Circula(on,  118,  2452-­‐2483.  doi:   10.1161/CIRCULATIONAHA. 108.190652   Cool It Methods •  Transfer patients –  standardized protocols –  ice during transfer •  STEMI – immediate angiography and PCI •  Cool Cath •  Blanketrol II •  Arctic Sun® TH device •  Target temperature 33°C for 24 hrs •  Rewarming at 0.5°C/hr •  Cerebral function at discharge Who?  
  9. 9. Therapeu(c  Hypothermia   1/8/13   Who to Cool? Inclusion Criteria •  Post-cardiac arrest: defined as absence of pulses requiring chest compressions, regardless of location or presenting rhythm –  Any Initial rhythm (VF/VT, asystole or PEA) •  ROSC within 20 minutes to a SBP > 90 mmHg (with or without vasoactive meds) •  Patient is comatose (unable to follow commands/ GCS < 6) upon arrival to the hospital in the absence of sedation •  Time at start of cooling is within 4 hours after ROSC Who to Cool? Exclusion Criteria •  Recent major surgery within 14 days - Hypothermia may increase the risk of infection and bleeding. •  Systemic infection/sepsis - Hypothermia may inhibit immune function and is associated with a small increase in risk of infection. •  Patients in a coma from other causes (drug intoxication, preexisting coma prior to arrest} •  Patients with a known bleeding diathesis or with active ongoing bleeding - Hypothermia may impair the clotting system. –  Check PT/PTT, fibrinogen value, and D-dimer value at admission. –  (Note: Patients may receive chemical thrombolysis, antiplatelet agents, or anticoagulants if deemed necessary in the treatment of the primary cardiac condition.) THIS DOES NOT exclude them! •  Patients with a valid do not resuscitate order (DNR) Who to Cool? Exclusion Criteria •  Multi-organ system failure •  refractory shock requiring high doses of vasopressors (MAP<60 on 2 or more vasopressor agents) •  severe persistent hypoxia, acidosis or co-morbidities with minimal chance of meaningful survival independent of neurological status •  Recurrent VF or refractory VT in spite of appropriate therapy should generate consideration of emergent referral for cardiac catheterization  
  10. 10. Therapeu(c  Hypothermia   1/8/13   Cool It Methods Who gets it?         GO   NO     non-­‐trauma(c    •  comatose  before  arrest   OOHCA    •  DNR/DNI     ROSC  within  20   min      •  ac(ve  bleeding     Unresponsive    •  terminally  ill     >  18  years  old   How? How to Cool •  Different cooling techniques are combined for optimal patient cooling. •  Induction cooling is accomplished initially with ice- chilled crystalloid infusion and ice packs followed by a cooling blanket system. •  Endovascular Cooling with Surface Cooling: –  Initially, 10 – 30 ml/kg ice-cold (4 degrees Celsius) crystalloid solutions (Lactated Ringer’s or Normal Saline) over 30 minutes –  Cooling apparatus (Blanketrol III) with the water temperature set to 93 degrees Fahrenheit (33 degrees Celsius).  
  11. 11. Therapeu(c  Hypothermia   1/8/13   Therapeutic Hypothermia •  Types –  Invasive •  Cooling catheter –  Cooled IV solutions (basic) Slush machines (advanced) –  Non invasive •  Water blanket •  Arctic sun Cooling Protocol •  Obtain laboratory tests ASAP: –  Beta HCG on all women of childbearing age –  Arterial blood gas –  CBC/ platelets / PT / PTT/INR, Fibrinogen –  Electrolyte “panel 7”, plus iCa / Mg / Phos , Cl-, Glucose –  Amylase, Lipase, LFTs, , Lactate, CPK-MB, CK, Troponin –  Blood Cultures, Urine Cultures, Urinalysis •  Toxicology screen if appropriate •  12 lead EKG, Chest X-ray •  Placement of urinary catheter with temperature sensor •  Insertion of Central Line Catheter (subclavian or IJ) How to Cool? Preparation •  Hypothermia therapy for patients with out-of-hospital cardiac arrest should be initiated in the emergency department. •  Treatment can be continued while in the PCI laboratory and in the ICU. •  Place an arterial line early for blood pressure monitoring as peripheral vasoconstriction will increase the difficulty of placing the line after the patient is cooled. •  A continuous core temperature monitor should be used; this provides data to modulate cooling efforts and to avoid overcooling.  
  12. 12. Therapeu(c  Hypothermia   1/8/13   What you might see! •  When using conventional surface cooling, sedation and chemical paralysis is usually necessary. •  Use of endovascular cooling can negate the need for paralysis •  Cooling must be performed rapidly to achieve maximum effectiveness and should be instituted as early as possible. •  Most studies have found it necessary to use both cooling blankets and ice packs to achieve the temperature goal. •  Other methods such as ice lavage, cold saline infusion, and endovascular methods may be used to help achieve target temperature. Go cold FAST!! Put it into PLACE! HYPOTHERMIA BUNDLE TIME ZERO Return Of Spontaneous Circulation (ROSC) 10 MINUTES COMPLETE Screening & Notify ICU Attending 15 MINUTES •  “Hypothermia Labs” To Be Sent Out • Start all lines place probe 30 MINUTES to Place Central Line In Subclavian 45 MINUTES Place Temp Sensing Foley Start Cold Saline START SURFACE COOLING 4 HOURS ACHIEVE TARGET TEMP OF 32 C RL  
  13. 13. Therapeu(c  Hypothermia   1/8/13   Proposed Grady Post-Cardiac Arrest Therapeutic Hypothermia Protocol •  Identification of eligible patients –  Comatose survivors after out-of-hospital cardiac arrest with a primary rhythm of VT/VF regardless of presence of shock. –  Hypothermia should be considered for non-VF rhythms and in-hospital cardiac arrest –  ≤ 20 min CPR prior to ROSC –  Pre-arrest GCS = 15 or independent ADLs Proposed GradyPost-Cardiac Arrest Therapeutic Hypothermia Protocol •  Identification of ineligible patients –  Written DNR/DNI –  Cognitive status severely impaired before arrest –  Underlying coagulopathy or bleeding disorder –  Other known reason for coma/arrest (e.g. septic shock, severe acidosis, trauma, etc.) –  Questionable head injury or head CT with mass or hemorrhage –  Unstable cardiac rhythms not terminated during initial management Proposed GradyPost-Cardiac Arrest Therapeutic Hypothermia Protocol •  Cooling induction –  If eligible, call a CODE ICE –  Assure nurse staffing with trained individual –  Perform required labs and tests –  Prior to cooling consider •  Intubate patient •  Insert arterial pressure monitoring line •  Insert CVC (preferably Edwards SVO2) catheter •  Insert temperature sensing Foley catheter •  OG tube placed •  Sedate with IV Midazolam or Propafol and Fentanyl •  Paralyze with Vecuronium to prevent shivering  
  14. 14. Therapeu(c  Hypothermia   1/8/13   Proposed Grady Post-Cardiac Arrest Therapeutic Hypothermia Protocol •  Cooling induction –  Target temperature and duration? •  33-°C for 24 h after reaching the target. •  Goal 4hrs to target temperature. –  Methods of induction? •  Up to 4 liters Ice-cold LR or NS 30 mL/kg with pressure bags via large bore cannulas, –  Avoid in patients with pulmonary edema or severely reduced LV systolic function. •  Combine with cooling device. –  Our institution has Blanketrol II readily available. Proposed GradyPost-Cardiac Arrest Therapeutic Hypothermia Protocol •  Maintenance –  Nursing to monitor Temp, MAP, CVP, ABG, standard vital signs, u/o in mg/kg/hour, SVO2, QTc, hourly & record on specific TH flowsheet –  Accucheck Q2 hours –  Labs q6h – Lactate, BMP, CBC, Trop/CK/CK-MB, ABG (corrected for temperature) Grady Post-Cardiac Arrest Therapeutic Hypothermia Protocol •  During maintenance –  Side Effect Monitoring •  Bradycardia higher risk if Temp < 30°C. •  Closely monitor for infection, no evidence for prophylactic antibiotics despite higher rates of sepsis & pneumonia •  Closely monitor for electrolyte imbalance. •  Potentially higher bleeding complications after PCI. –  Platelet function unaltered by hypothermia. •  Altered drug action and metabolism. –  Reduces systemic clearance of cytochrome P450 metabolized drugs between 7%-22% per °C. •  Paralyze to prevent shivering  
  15. 15. Therapeu(c  Hypothermia   1/8/13   Cooling Monitoring •  A mean arterial pressure (MAP) goal of more than 80 mm Hg is preferred from a cerebral perfusion standpoint. •  Hypertension is potentially additive to the neuroprotection of hypothermia. –  Norepinephrine can be used, beginning at 0.01 mcg/kg/min and titrated to a MAP greater than 80 mm Hg. •  The treating team should determine the MAP goal, balancing the cardiac safety with the theoretical advantage of higher cerebral perfusion pressures •  blood pressure remains elevated during hypothermia as a result of peripheral vasoconstriction. •  Hypotension is a concern during the warming phase. Electrolyte and Fluid Shifts •  As you cool the patient, vasoconstriction will decrease effective vascular volume. –  Diuresis –  Lose potassium –  Lose phosphate –  Potassium shifts intracellularly What happens when you cool •  Dehydration, ileus and fluid shifts with body temperatures below 32 º C. •  Electrolyte imbalances. –  Hypothermia masks potassium-induced changes in the electrocardiogram. •  Cold-induced renal glycosuria •  Oxygenation indicators shift to left!!!  
  16. 16. Therapeu(c  Hypothermia   1/8/13   Shift to the left… What happens when you cool •  Coagulopathies despite normal clotting factor levels because cold directly inhibits the enzymatic reactions of the coagulation cascade. –  Not reflected normal PT or PTT, since these tests are routinely performed only at 37 °C. •  Platelet activity declines because thromboxane B2 production is temperature-dependent. •  Cold-induced thrombocytopenia from direct BM suppression and hepatosplenic sequestration •  Hematocrit increases 2% per 1 degree º Celsius decline in temperature •  Hypercoagulability occurs with possible thromboembolism. –  Danzl, Accidental hypothermia, N Engl J Med 1994. Keep them COLD But be aware…..  
  17. 17. Therapeu(c  Hypothermia   1/8/13   Electrolyte and Fluid Shifts •  As you cool the patient, vasoconstriction will decrease effective vascular volume. –  Diuresis –  Lose potassium –  Lose phosphate –  Potassium shifts intracellularly When cooling you might see this…. Osborn Waves  
  18. 18. Therapeu(c  Hypothermia   1/8/13   ECG changes: Osborn Waves Cooling Monitoring •  Monitor the patient for arrhythmia (most commonly bradycardia) associated with hypothermia. •  If life-threatening dysrhythmia arises and persists, or hemodynamic instability or bleeding develops, then active cooling should be discontinued and the patient rewarmed. •  Heart rate less than 40 is frequent and is not a cause for concern in the absence of other evidence of hemodynamic instability. Once they are cool! •  Decreased oxygenation –  Shifts oxyhemoglobin-dissociation curve to left –  Vasoconstriction –  VQ mismatch –  Increased blood viscosity •  Metabolic acidosis –  Lactate generation due to shivering and decreased tissue perfusion –  Impaired hepatic metabolism and impaired acid excretion. •  Danzl, Accidental hypothermia, N Engl J Med 1994.  
  19. 19. Therapeu(c  Hypothermia   1/8/13   Blood Gases and Temperature •  When a patient is cooled, –  pCO2, pO2 decrease –  pH increases, measured at the patient’s temperature.     At  37ºC  in  Machine:  7.35  /  45  /  100   At  33ºC  in  Pa:ent:  7.41  /  40  /  90   Renal •  Cold induced diuresis occurs due to a decrease in absorption in the nephron •  Resistance to vasopressin and ADH leading to further diuresis •  Hypothermia causes K to shift into the cells resulting in hypokalemia •  Rewarming occurs potassium shifts back in to the plasma leading to hyperkalemia Hematologic System •  Hemoconcentration occurs due to cold diuresis and third spacing of fluid related to increased vascular permeability and leads to an increase in blood viscosity •  Decrease in # and function of WBC’s leading to increased of infection •  Decrease in # and function of platelets predisposing to bleeding •  Coagulopathies occur due to disruption of enzyme reactions in clotting cascade  
  20. 20. Therapeu(c  Hypothermia   1/8/13   Cooling Monitoring •  Hematologic testing recommendations include CBC count, Chem 7, troponin level, arterial blood gas (ABG) level, and PTT at 0 hours. •  Hypothermia commonly causes hypokalemia, which may be exacerbated by insulin administration. •  When patients are rewarmed, potassium exits cells, and hyperkalemia may occur. •  Repeat measurements of glucose, K+, and ABG are needed every 6 hours. Cooling Monitoring •  Hematologic testing recommendations include CBC count, Chem 7, troponin level, arterial blood gas (ABG) level, and PTT at 0 hours. •  Hypothermia commonly causes hypokalemia, which may be exacerbated by insulin administration. •  Repeat measurements of glucose, K+, and ABG are needed every 6 hours during cold times Cooling Monitoring •  Potassium values less than 3.5 mEq/L should be treated while the patient is being cooled. •  Potassium administration should be stopped once rewarming begins. •  Skin should be checked every 2hours for thermal injury caused by cold blankets •  Do not provide nutrition to the patient during the initiation, maintenance, or rewarming phases of the therapy.  
  21. 21. Therapeu(c  Hypothermia   1/8/13   Once they are cool! •  Shivering is a concern when trying to achieve a hypothermic state. •  Shivering prevents the patient from achieving his temperture •  Shivering is uncomfortable, and generates heat, interfering with the cooling process. •  Shivering leads to warming •  Increases oxygen consumption •  Use sedation and muscle relaxation to stop shivering Stop the shivering! "##$%&(!)! Basic Shivering Assessment Score (BSAS)1,2 Score Severity of Shivering Definition 0 None No shivering noted on palpation of the masseter, neck, or chest wall 1 Mild Shivering localized to the neck and/or thorax 2 Moderate Shivering involves gross movement of the upper extremities (in addition to neck and thorax) 3 Severe Shivering involves gross movements of the trunk and upper and lower extremities !"#$%A! !"#$%G! !"#$%&! ?BB6/(1-,%"*3-)635%6C%H3.355-+! $()*+,-./.%0123431/(15! !3B-/(1%-1B%?1-,;356-! K+L&9&M(!=%(!#-!#$(!+,($*!/)&#)!*#!+&$,! "#$%&()!%*+$&$,!#)()%!-#)!+..!/+0($*%!! K+L&9&M(!=%(!#-!#$(!+,($*!/)&#)!*#!+&$,! $(L*!*#!9+&$*+&$!2343!%5#)(!N!7! $(L*!*#!9+&$*+&$!2343!%5#)(!N!7! 1#+.!2343!%5#)(!6!#)!789#$&*#)!(:();!<#=)! 4:+$5(!-)#9!%*(/!O!*#!%*(/!I!><($!2343! 4:+$5(!-)#9!%*(/!7!*#!%*(/!O!><($!2343! %5#)(!a!7!(%/&*(!9+L&9&M&$,!3*(/!7!d!O! %5#)(!O!DP!I! &$*():($0#$%! $-55643%!761%.(81239-:61;% $()(C(,!76!95,E@,E9&$!QR!5#$0$=#=%! I3>:3B32(:6B613!6S7!W!6SX!95,E@,E<)!QR! <-.3=%13.7=%3>23:6/35%9-:61;! &$-=%&#$S!!T&*)+*(!U;!7695,E@,!VI9&$!*#!2343! 5#$0$=#=%!&$-=%&#$!+$!0*)+*(!*#!2343!e7S!! 4//.;!>+)9!*#>(.%!+)#=$!<(+?!$(5@?!<+$%! 6W7S!K+L&9=9!B6!W!XB!95,E@,E9&$!! K+L&9=9!7!95,!E@,E<)! +$!-((*! Y)2%:852%D3%6128D-23BZ! <312-1+,!7!*#!H!95,E@,E<#=)!QR!5#$0$=#=%! &$-=%&#$S!T&*)+*(!*#!2343!6W7!! F3C-.2(+%2(%-,,%2*3%-D(43% Y)2%:852%D3%6128D-23BZ! ?.32-:61()*31%AB6!9,!CDEF1!GH<! @85)6(13%I6!9,!CDEF1!G!J!<)%!! E3)36B613!OB9,!QR!VH<!/)$!DP!GA[! 3"[]^_]S!! ?2-.868:!6SB!9,E@,!QR!U#.=%!-#..#>(!U;!B! 95,E@,E9&$!5#$0$=#=%!&$-=%&#$SY)2%:852%D3% YP(=5(!#%(!U;!`!&$!/+0($*%!a!AB!;(+)%!#.S! 6128D-23B%-1B%53B-23BZ! 4:#&!&$!/+0($*%!>&*<!)($+.!&$%=b5&($5;!+$! <&%*#);!#-!%(&M=)(%Z! T&*)+*(!*#!TDc!IWH!+$!2343!6W7! ! Complications of Cooling •  Hypovolemia (hypothermia induced diuresis) •  Coagulopathy (impaired coagulation cascade and thrombocytopenia) •  Electrolyte disorders (hypothermia induced diuresis, K, Mg, Ca) •  Insulin resistance •  Changes in drugs effects and metabolism (altered clearance of fentanyl, midazolam, and atracurium)  
  22. 22. Therapeu(c  Hypothermia   1/8/13   Development  and  implementa:on  of  a  therapeu:c   hypothermia  protocol.   Kupchik  NL     Cri(cal  Care  Medicine.    37(7  Suppl):S279-­‐84,  2009  Jul.     4   Complications of Therapeutic Hypothermia Need for paralysis to control shivering •  Glucose increases •  Potassium, magnesium and phosphate all decrease •  Increased infections “They said I had ice on me for more than a day but I don’t remember…. I don’t remember anything but the nurses voice telling me I was gonna be OK and I believed her…. I think my family was there for awhile… the nurse was always there”….. Male patient 47 years old, treated with fentanyl, versed, propofol and pancuronium  
  23. 23. Therapeu(c  Hypothermia   1/8/13   Expect and Anticipate •  Widened QRS •  ST segment elevation or depression (always consider ischemia/infarction first) •  QT interval may be prolonged hours or days after warming •  Hypokalemia! Treat < 3.5 •  Coagulopathy •  Lots of urine •  dehydration Complications •  Low cardiac index •  Arrythmias •  Pneumonia •  Sepsis •  Bleeding •  Local cold injury •  Rebound hypothermia(afterdrop phenomena) Warm real sloooooooow!  
  24. 24. Therapeu(c  Hypothermia   1/8/13   Proposed GradyPost-Cardiac Arrest Therapeutic Hypothermia Protocol •  Rewarming –  Goal is to rewarm over 8-12 hours –  Using Blanketrol II increase warming blanket setting by 0.5°C every 1-2 hours –  Discontinue when patient reaches 36°C. –  Maintain normothermia (36.5°C-37.5°C) up to 72 hrs after cardiac arrest. Rewarming: SLOOOOOOOOW •  Remove cooling blankets (and ice if still in use) •  The goal is to have the patient warm at about 0.5ºC per hour up to a target of 36°C. •  Maintain the paralytic agent and sedation until the patient’s temperature reaches 35°C. •  Monitor the patient for hypotension secondary to vasodilatation related to rewarming. •  Discontinue potassium infusions. •  The goal after rewarming is normothermia (ie, avoidance of hyperthermia). Absolutes!!!!!! •  During Re-warm phase: –  DO NOT give Mg or K replacements (if infusing, halt when re- warm phase begins) •  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) –  DO NOT bathe patient –  Try not to flush bowel management system –  Try not to flush Foley catheter •  Avoid off-unit trips and/or time off the device until patient’s temp reaches at least 36.5ºC  
  25. 25. Therapeu(c  Hypothermia   1/8/13   Additional Monitoring •  Monitor glucose q2hr •  Monitor serum potassium q4hr –  When patients are rewarmed, potassium exits cells, enters serum and hyperkalemia may occur •  ABG q4hr is also indicated –  Expect big drop on Sa02 and Pa02 Post Re WARM •  During Post re-warm Normothermic Phase: –  Keep Arctic Sun operational @ 37ºC for AT LEAST 24 hrs post re-warm completion or as directed by Hypothermia Team. –  For fever determination, compare charted patient and water temp trends INSTEAD of stopping active temp control. –  When going to CT / MRI, pads should remain in place if at all possible. –  Put the original (or copy) of Timeline sheet in the patient’s chart when normothermic phase has been completed / prior to chart leaving the unit. Shift to the Right…  
  26. 26. Therapeu(c  Hypothermia   1/8/13   How do you know it worked? I’m not sure where I am or what happened… my wife said I died…. the nurse knows what happened  
  27. 27. Therapeu(c  Hypothermia   1/8/13   Setting Up the Patient Induction: Maintain target temp for Rewarm phase (criteria review) 4 hours to Target Temperature 24 hours after reaching target temp should take 12-24 hours 1. Cardiac arrest (VTach/Vfib) After all labs and tests performed, initiate cooling •Control Shivering •Be aware of electrolyte imbalance {opposite of cooling process: Time?_____ •Be aware of electrolyte imbalances {opposite ( K+ inc. Glucose dec.)} • Cautiously Administer 2 Liters 0.9 NS at 40 2. Arrest Rhythm___________ Celsius over 60 minutes ( find in cooler/fridge) of rewarm( K+ dec. Glucose inc. )} • caution! hypotension! ROSC (return circulation) • Place blanket and leg wraps on patient as closely as • consider replacing clotting factors if at risk or • caution! hypovolemia Time?_____ Rhythm_____ possible, but lay out headpiece. abnormal • caution! hypoglycemia • Check water level in cooler and if necessary fill with 3. Comatose? GCS_______ distilled or sterile water ONLY. • caution! hypertension • caution: afterdrop phenomena 4. >18 years of age • Assure all cables connected • caution! cold diuresis • *Turn off K+ and Insulin Drips 5. If all YES, notify MICU team • Turn machine on, after a few blinks will read “ck set • caution! hyperglycemia Rewarm at 0.30- to 10 per hour : Assure probe in pt”, push temp set button and assure temperature is • bradycardia OKAY 50 BPM as long as stable place set at 33 degrees (toggle tempest button) • Push AUTO CONTROL button to initiate the flow of • < 50 BPm notify physician manually adjust at blanketrol 111 monitor every hour cold fluids • Careful! replacement of K+ only below 3.5 until patient reaches 37 0 • NOW place head wrap on patient assuring all cables and not above 4.0, other replacement of • If patient has complications of hypothermia on same side and a comfortable fit electrolytes as necessary (bleeding, arrhythmias, ischemia) the rewarming rate may increase to 1°C (but NO greater) per hour. Goal: decrease temperature to 330 by 4 Goal: maintain temperature at 330 for 24 hours with minimal complications hours with minimal complications Goal: reach normothermia within 24 hours of rewarm initiation with minimal complications: Rewarm slow!!!! ECC charge nurse calls “CODE ICE” Initiate Active Cooling! Assure probe in place maintain at 330 : Assure probe in place Nursing communication: Rewarming to begin 24 hours Discontinue and rewarm before 24 hours ONLY if AFTER reaching target temperature of 33ºC Target Temperature at 4 hours! •Patient wakes up • Document time rewarming begins Obtain KOOLKIT, rectal probe and Target 330 •DNR or pronounced • Discontinue insulin drip (if present) Blanketrol 111 Nursing communication: patient may •Refractory bleeding Patient often experiences hypoglycemia during hypothermia. Be alert to experience cold diuresis. Notify physician if urine •Refractory dysrhythmia trends! Treat as required by physician. • Nursing communication: Do not adjust • Discontinue K+ infusion (if present) All transport tests and central output is > 200 ml per hour. temperature or withdraw protocol if patient • Nursing communication: K+ may increase as fluids and catheterizations MUST be done prior to Nursing communication: Discontinue (and experiences shivering. Use BSAS protocol acids shift induction if at all possible! progress to rewarming) with PHYSICIAN Order approach for shiver control. • Nursing communication: Maintain paralytic until • If Patient wakes up • Nursing communication: If patient awakens and temperature of 35°C is reached. Discontinue paralysis at 35°C neurological status has improved (patient follows • Nursing communication: Discontinue sedation when TOF • Patient is declared DNR reaches 4 twitches commands) at any time during the cooling or • Suffers from refractory life threatening rewarming phase protocol, notify physician team, • If temperature is refractory to warming, notify Physician dysrhythmia (all therapies fail to control discontinue hypothermia methods and allow the (consider hypothyroidism, particularly if history of Amiodarone dysrhythmia) patient to passively rewarm therapy). • Suffers from refractory bleeding (all therapies fail to control bleeding) 1. Assure 2 initial intravenous catheters 1. Monitor VS Q15 x1 hour 1. Monitor VS Q1 hour 1. Turn off NMB (if present) at temperature 350 2. Set up for Central and arterial line 2. Then monitor VS Q1 hour 2. Monitor urine output Q1 hour, I and O 2. Monitor TOF Q1 H placement 3. Monitor urine output Q1 hour, I and O 3. BSAS Q1H and medicate according to 3. Consider reduction of sedation when TOF at 4 3. Place on Stryker bed with pressure 4. BSAS Q1H and medicate according to protocol 4. Monitor VS Q1 hour relief low air loss mattress prior to protocol 4. Document QTC Q2 hour 5. Monitor urine output Q1 hour, I and O induction ( available in CDU or MICU), 5. Document QTC Q2 hour 5. Accucheck Q2 H 6. Document QTC Q2 hour Weigh patient and document 6. Accucheck Q2 H 6. Complete assessment Q2 H 7. Accucheck Q2 H 4. Assure mechanical ventilation and 7. Complete assessment Q2 H 7. Turn and assess skin Q2 8. Complete assessment Q2 H respiratory therapy availability 8. Turn and assess skin Q2 8. May require vasodilators 9. May require vasopressors 5. Place O-G tube 9. Adjust vasopressors accordingly 9. Replace urine output with fluids (per Dr.) 10. Replace urine output with fluids (per Dr.) 6. Place foley catheter 10. replace urine output with fluids (per Dr.) 10. Daily weight 11. Turn and assess skin Q2 7. Place rectal probe 11. target temperature reduction by 4 hours 11. Provide skin care as per protocol 12. Seizure precaution 8. Complete vital signs, neuroassessment 12. Provide skin care as per protocol 12. seizure precaution 9. Initiate IV analago-sedation 13. seizure precaution Baseline Labs: CMP (14), Mag+, Ca++, Labs Every 6 Hours: CBC, CMP, Mag+, Ca++, Labs Every 6 Hours: CBC, CMP, Mag+, Ca+ Labs Every 4 Hours: CBC, CMP, Mag+, Ca++, DIC DIC Panel, CBC, CPK-MB, Troponin, DIC panel, ABG, VBG ( if central or mixed +, DIC panel, ABG, VBG ( if central or mixed panel, ABG, VBG ( if central or mixed venous line), Lactate, ABG, B-HCG urine for pregnancy venous line), Troponin, Lactate venous line), Troponin, Lactate Troponin, Lactate (females<50 years), TSH,T4 Chest radiograph, 12 lead ECG CXR Q 24 as necessary, ECG 12 LEAD CXR Q 24 as necessary, ECG 12 LEAD CXR Q 24 as necessary, ECG 12 LEAD Therapeutic Hypothermia Phone Tree “CODE ICE” ECC notifies operator: Dial 911 404-616-2652 1st operator calls Bed Planners Directly 404-616-2669 (Confidential Numbers) 2nd operator sends CODE ICE TEXT House Supervisor MICU EVS Bed Czar Barbara McLean Dina Dent Administrator Charge Nurse Supervisor 404-319-7367 Randy Crawford 678-260-7814 Sandra Straker 404-754-6229 678-575-4028 (4 pm - 7 am Only) 404-859-5034 (24, 7) 404-576-7921 (24, 7) (24, 7) (7:00 am - 3:30 am) Angela Brown 404-859-5035 Randell Green 404-938-6986 Charles Jenkins (3:00 pm - 11:30 am) 404-859-5036 Fri, Sat, Sun Only Rodriguez Scott 404-448-6256 (11:00 pm - 7:00 am) This document contains confidential information - do not distribute  
  28. 28. Therapeu(c  Hypothermia   1/8/13   Quick Review: Essential Points •  Techniques –  Sedation –  Cold IV NS bolus x 2 liters –  Ice Pillows –  Active cooling system –  Cool to 33ºC <4 hours –  Maintain for 24 hours –  SLOW re-warm <0.5ºC/hr •  Side Effects –  Shivering (use sedation ± paralytics) –  Cold diuresis (replace Mg, K) –  Insulin resistance (need insulin drip) –  Seizures (consider continuous EEG) –  Hypotension (pressors) –  Coagulopathy (FFP, platelets) •  Post-re-warm fever (keep cooling methods on /in) for 24 hours Successful Therapeutic Hypothermia Re-evaluate every time Adjust to re-evaluation Don’t be afraid! Set goals and expectations! The Family….. DOOR sign reminder  
  29. 29. Therapeu(c  Hypothermia   1/8/13   Stay Cooooooooool! Nice Ice Baby! B.McLean, MN, RN, CCRN, CCNS, NP-BC, FCCM 404-626-2843