This document discusses targeted temperature management (TTM), previously known as therapeutic hypothermia. It provides background on the mechanisms, history, recommendations and methods for TTM. Key points include that inducing mild hypothermia (32-36°C) for 24 hours after cardiac arrest can reduce neurological injury and improve outcomes. Several methods are described for cooling patients, including surface cooling with blankets/pads and internal cooling via intravenous fluids or catheters. Guidelines recommend TTM for comatose cardiac arrest patients with return of spontaneous circulation.
Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483
Post-Cardiac Arrest Syndrome:
Epidemiology, Pathophysiology, Treatment, and Prognostication
A Consensus Statement From the International Liaison Committee on Resuscitation
Circulation. 2008;118:2452-2483
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
SOLACI Coverage: AHA 2012 Congress. Dr. Esteban Lopez-de-Sa . PILOT trial: El estudio piloto de dos niveles de hipotermia en los sobrevivientes comatosos tras un paro cardiaco fuera del hospital. Find more presentations on our web http://solaci.org/es/aha_2012.php
A presentation for EMS personnel about prehospital cooling of patients with return of spontaneous circulation in the field post cardiac arrest; research and application
Perinatal asphyxia is an insult to the fetus or the newborn due to lack of oxygen (hypoxia) and or a lack of perfusion (ischemia) to various organs. Hypoxia ischemia remains a significant cause of neonatal mortality and morbidity and adverse neurodevelopmental outcome. Therapeutic hypothermia found to improve neurodevelopmental outcome in asphyxiated babies.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
3. TARGETED TEMPERATURE
MANAGEMENT
Previously known as Therapeutic
hypothermia or Protective hypothermia
Specific body temperature x specific duration of
time
To prevent Ischemia related injury to brain
After a cardiac arrest or other causes of ischemia
Concept very old
But accepted treatment only since last 15 years
5. EFFECTS OF HYPOTHERMIA
Decreases metabolic demand - 1 degree fall in temperature
decreases O2 consumption by 6%
Attenuation and/or reversibility of ischemic depolarization of the
central nervous system (CNS)
leading to membrane stabilization, electrolyte redistribution, and
normalization of intracellular water concentration and
intracellular pH (stabilization of the blood-brain barrier)
Reduces release of excitatory amino acids
Attenuation of lipid peroxidation & oxygen free radical production
Restoration of calcium modulation
Inhibition of deleterious signaling mechanisms, such as apoptotic
signaling
Inhibition of deleterious inflammatory products (ie, cytokines,
interleukins, arachidonic acid cascade end products)
Inhibition of cytoskeletal breakdown
Decreases ICP.
6. HISTORY
First description of cold as treatment modality -
Edwin Smith Papyrus, an ancient Egyptian
treatise on medicine and surgery ,5000 years ago
Hippocrates advised snow and ice packing to
reduce hemorrhage in the wounded
Total body cooling was used for tetanus
treatment in the fourth- and fifth-century
Late 1700s, Dr James Currie Scottish physician -
first systematic experiments on humans to
determine the effects of various methods of
cooling upon body temperature, pulse, and
respiration.
1803 - Russian method of packing in ice
Baron de Larrey, Napoleon’s chief surgeon
observed that wounded soldiers kept closer to a
fire died faster than those who were neglected.
7. HISTORY
Dr Temple Fay -credited with reintroducing
therapeutic hypothermia to modern day
medicine
In his famous experiment in 1938
Used induced hypothermia to relieve
pain from metastatic breast cancer
(32°C for 24 hours).
Invented one of the earliest “cooling
blankets”
Advised the same for traumatic brain
injury
1950s - Bigelow and colleagues
documented positive physiological effects
of hypothermia on the brain during
cardiac surgery in animals
Late 1950s to 1960 was common practice
in neurosurgical procedures
8. HISTORY
1958 - The first clinical trial of hypothermia in the
treatment of comatose patients following cardiac arrest
was published
50% survival for patients (6 of 12) managed with
hypothermia at 33°C compared to 14% (1 of 7) of
patients in the normothermic group
1964 - became a part of the first published algorithm on
heart–lung resuscitation
Advocated cooling patients within 30 minutes of the
return of spontaneous circulation if there were no
signs of central nervous system recovery.
Further interests declined due to side effects until it
became evident that even mild hypothermia has
potential benefits
1990s - again became common practice
9. 2002 – 2 RCTS
In 2002 - 2 landmark RCTs were published in NEJM
by independent researchers in Europe & Australia.
10. BERNARD et al
Melbourne
77 Patients randomized to Hypothermia (33°C for 12 h) &
Normothermia group
Demonstrated that 49% of hypothermia-treated patients
survived versus 26% of control patients, with odds ratio
(OR) = 5.25 in benefit of hypothermia.
THE HYPOTHERMIA AFTER CARDIAC ARREST STUDY GROUP
TRIAL (HACA TRIAL)
9 centres in five European countries
Demonstrated better neurological outcomes in the
treated group
275 were randomly assigned to the hypothermia (32–
34°C for 24 h) & normothermia group
Observed Increased recovery (55% vs 39% in the control)
as well as lower 6-month mortality (41% vs 55%).
11. In 2003
ILCOR (International Liaison Committee on Resuscitation ) endorsed
the use of targeted temperature management following cardiac arrest.
12. AHA GUIDELINES
Recommendations 2005 2010 2015
OHCA-VF/p-VT IIa Class I, LOE B Class I, LOE B
Non VF OHCA IIb Class IIb, LOE B Class I, LOE C
IHCA IIb Class IIb, LOE B Class I, LOE C
Temperature &
Duration
Strength of evidence
32-34°C
12-24 hrs
Poor
32-34°C
12-24 hrs
Poor
32-36°C
24 hrs
Class I LOE B
Active rewarming of
spontaneous mild
hypothermia (> 33°C)
Class III, LOE C Class III, LOE C Class III, LOE C
13. 2015 AHA ACLS
Comatose (ie, lack of meaningful response to verbal
commands) adult patients with ROSC after cardiac arrest
have TTM
Class I, LOE B for VF/pVT OHCA
Class I, LOE C for non-VF/pVT (ie, “nonshockable”) & in-
hospital cardiac arrest).
Selecting and maintaining a constant temperature between
32ºC and 36ºC during TTM. (Class I, LOE B)
Specific Feature of individual patient will determine the
target tempertaure
It is reasonable that TTM be maintained for at least 24 hours
after achieving target temperature. (Class IIa, LOE C)
14. 2015 AHA ACLS
Recommends against the routine prehospital cooling of
patients after ROSC with rapid infusion of cold intravenous
fluids. (Class III: No Benefit, LOE A)
It may be reasonable to actively prevent fever in comatose
patients after TTM. (Class IIb, LOE C)
Hemodynamically stable patients with spontaneous mild
hypothermia (>33°C) after resuscitation from cardiac arrest
should not be actively rewarmed
16. IDEAL TEMPERATURE 34 VS 36 °C
ILCOR , 2005 & 2010 AHA guielines recommended a
target temperature of 32 – 34 °C
The 2015 guideline revised the target temperatures
of 32-36 °C, which only some institutions have
adopted so far
This was following a large RCT in 2013 & a
subsequent meta analysis in 2015 which confirmed
the results
In 2015 ILCOR adopted the term targeted
temperature management (TTM).
17. 2013
950 OHCA patients
Randomised to 33 & 36 °C
Primary outcome – all
cause mortality
Secondary outcome -
composite of poor
neurologic function or
death at 180 days
Hypothermia at a targeted
temperature of 33°C did
not confer a benefit as
compared with 36°C
20. SURFACE COOLING WITH
ICE PACKS
Inexpensive but messy
Appropriate way to initiate cooling.
Less than optimal in the rate of
cooling and temperature
maintenance.
Ice packs placed in anatomic areas
with large heat-exchange capability
(the head, neck, axillae, and groin)
Replaced when the ice packs have
substantially melted.
In addition to ice packs
evaporative cooling with fans also
used.
Average temperature drop -
moderately slow and highly variable
0.03°0.98°Celcius per hour.
21. NEWER SURFACE
COOLING SYSTEMS
Works by circulating cold fluid or cold air through
blankets or pads that are wrapped around the
patient
The temperature of the circulating fluids can be
adjusted
Cooling blankets
Surface cooling pads
Many of them has auto feed back mechanism to
adjust the temperature of the circulating fluids.
22. COOLING BLANKETS
Curewrap™ with CritiCool by MTRE, Yavne, Israel
Kool-Kit® with Blanketrol III by Cincinnati
Sub-Zero, Cincinnati
Conventional surface cooling blankets are also suboptimal
because of poor surface contact with the patient’s skin.
Combination with ice packs are effective at rapidly cooling
patients and are fair at maintaining target temperature
Once target temperature is achieved , ice packs removed &
blanket used for maintenance
23. SURFACE COOLING PADS
Better heat exchange due to conducting gels
Superior cooling rate than cooling blankets.
InnerCool STX Philips ,Netherlands (non adhesive
surface pads)
Artic Sun® by Medivance, Louisville (adhesive pads)
EMCOOLS cooling system Vienna, Austria –
adhesive non-invasive HypoCarbon® pads with a
carbon-based cooling gel and provides cooling rates
of 3.5°C/h.
25. SURFACE COOLING
ADVANTAGES
Ease of application and rapid initiation of treatment.
Most devices has computerized auto-feedback mechanisms -
Set target temperature and the system modifies the coolant
temperature using the feedback from patient’s skin and core
temperature sensors.
DISADVANTAGES
Rare risk of skin burns and skin irritation
The initiation of hypothermia varies between different
devices and can range from 2–8 hours.
Shivering is more commonly seen with surface systems than
with other systems which may necessitate the use of muscle
relaxants & sedatives
26. SURFACE COOLING HELMET
Contains a solution of
aqueous glycerol that
facilitates heat exchange.
Although this method
works, it may be slower
than other methods.
28. COLD INFUSIONS
4°Celcius
Saline or Ringer Lactate
30 mL/KG (2 L)
Given over 30-60 mins
Temperature reduction upto
2.5°C
Given through peripheral line
or femoral Vein.
Not to be given by subclavian
or internal jugular vein
29. CATHETER BASED CORE COOLING
Uses endovascular heat-exchange catheters.
Placed into central vein (Femoral , IJV ,Subclavian)
Heat exchange occurs between cooled saline that
passes through the heat-exchange portion of the
catheter and the blood that flows over the outer
surface of the catheter.
2 devices currently available on the market:
Thermoguard XP temperature management
system (Zoll)
InnerCool RTx with Accutrol catheter (Philips).
31. CATHETER BASED CORE COOLING
ADVANTAGES
Has computerized temperature control with an auto-feedback
mechanism.
Faster cooling (1.46 -1.59°C/h) and precise temperature control
during all 3 stages
Fewer incidences of failure to reach target temperature than other
systems
Less overcooling than other systems.
Less shivering compared to surface devices.
Sedation & paralysis not required
DISADVANTAGES
There was no difference in outcome when compared to surface
cooling systems
Added risk of catheter-related bloodstream infection, venous
thrombosis and complications related to insertion of intravascular
lines
32. TRANS NASAL
EVAPORATIVE COOLING
RhinoChill device –battery-operated device composed of a
control unit, coolant bottle and a transnasal cooling catheter
Two 10 cm long nasal catheter prongs inserted
Perfluro carbon coolant mixture in sprayed into the nasal cavity.
Cerebral hypothermia is induced by
Evaporation of coolant into skull cavity
Conduction - Rapid cooling of skull base
Convection - Cooling of blood in adjacent blood vessels
The coolant that is expelled by the lungs in gas form is inert and
nontoxic.
33. TRANS NASAL
EVAPORATIVE COOLING
ADVANTAGES
Portable & simple -Can be used by nonmedical
personnel in the field
Rapid intiation of therapeutic hypothermia
Continue maintaining the temperature while the
patient is actively resuscitated transported.
Enables brain cooling even in the absence of blood
circulation.
DISADVANTAGES
Minor – Epistaxis , Cold injury nose
34. OTHER METHODS
CRRT
Some positive reports for continuous renal replacement therapy
(CRRT) for induction and maintenance of hypothermia
Selective brain cooling by hypothermic retrograde jugular vein flush
Relevant in conditions where whole body hypothermia may be
detrimental.
Intrapulmonary perflurochemical fluids
For induction and maintenance of hypothermia and also to
support gas exchange
The esophageal route
Also being investigated,
Because of the close proximity of the esophagus to blood flow
from the heart and great vessels
36. INCLUDED PATIENTS
Post cardiac arrest
ROSC within 60 mins
Duration of arrest <6 hrs
Maximum down time 15 mins
Able to maintain a systolic blood pressure >90 mm
Hg (with or without pressors)
Patient with GCS < 3
37. CONTRAINDICATIONS
Not maintaining MAP 65 mmHg 30 mins after ROSC
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.
Coma from other causes (drug intoxication, preexisting coma
prior to arrest)
Known bleeding diathesis or with active ongoing bleeding -
Inappropriate for patients with DNR order
Not recommended for an isolated respiratory arrest.
Reccurrent arrhythmia
Intrcranial Haemorrhage
Frank pulmonary edema
38. 3 STAGES
INTIATION
• Intentional change from current temperature to lower
temperature
MAINTAINENCE
• Maintenance of target temperature for specific time
duration
REWARMING
• Temperature increased at a slower & specific rate to a
normothermic target
39. TREATMENT GOAL
24 hours X 32ºC-36ºC.
Intiate at the earliest. Each 1 hr delay - increases
mortality by 20 %.
Achieve the target temperature as quickly as possible.
Most cases - achieved within 3-4 hours of initiating
cooling.
Rewarming - 24 hours after the time of initiation of
cooling (not from the time the target temperature is
achieved).
More evidence is needed to define the optimal duration
of hypothermia treatment in humans
40. PATIENT PREPERATION
Should be initiated in the emergency department.
Can be continued while doing PCI.
Continuous core Temperature measurement is done
Foleys Catheter with probe commonly used (but adequate
urine output required) . Otherwise esophageal or rectal.
Most ideal - PA probe.
Place an early arterial line -
Vasoconstriction will make placing the line later difficult
Surface cooling methods- sedation , analgesia and chemical
paralysis is usually necessary.
Use of endovascular cooling can negate the need for
paralysis
Buspirone and meperidine - lower the shivering threshold
DVT prophylaxis
41. INTIATION
A combination of surface and internal cooling is
usually used
2 cooling blankets (to sandwich) or Heat-exchange
Pads
Pack the patient in ice (groin, chest, axillae, and sides
of neck) Avoid packing on top of the chest - impair
chest wall motion.
Use additional measures as needed to bring the
patient to a temperature between 32ºC and 34ºC.
Continuous cardiac monitor, with particular
attention to arrhythmia detection and hypotension ,
regular O2 saturation measurement
42. MAINTENANCE &
SUPPORTIVE TREATMENT
Feedback mechanisms used to modulate the amount of
cooling provided.
MAP goal > 80 mm Hg is preferred
Norepinephrine at 0.01 mcg/kg/min starting dose and
titrated to a MAP greater than 80 mm Hg.
Practice standard neuroprotective strategies such as placing
the head of the bed at 30º
Monitor the patient for arrhythmias
Osborn waves often seen.
Heart rate < 40 bpm is frequent
Arrhythmia & bleeding – rewarming to be intiated.
Investigations
CBC RFT LFT Blood sugar electrolytes troponin level, ABG,
APTT PT-INR at baseline
Glucose, K+, and ABG every 6 hours
43. MAINTENANCE &
SUPPORTIVE TREATMENT
Cooling – Decreases K+ , Increases Blood sugar
K+ < 3.5 mEq/L should be treated
Hyperglycemia delitirous – no guideline but strict
control recommended
Normocarbia advised (35-45 mm Hg for PaCO2)
Avoid hypoxia & hyperoxia (SPO2> 94% recommended)
Skin checked every 2-6 hours for thermal injury
Regularly temperature check with a secondary
temperature monitoring device .
No nutrition during all 3 phases.
Avoid fever
44. CONTROLLED REWARMING
Most critical
Peripheral Vasodilatation - hypotension.
Recommended speed -0.3ºC-0.5ºC every hour.
Approximately 8-12 hours required .
Remove cooling blankets (and ice if still in use).
Cooling Pads & Catheter based devices may be set
at 35°C
Increase the water temperature by 0.5°C every 1-2
hours until a stable core body temperature of 36°C
has been reached for 1 hour.
45. CONTROLLED REWARMING
Maintain the paralytic agent and sedation until the
patient’s temperature reaches 36°C.
Discontinue the paralytic agent first. The sedation
may be discontinued at the practitioner’s
discretion.
Monitor the patient for hypotension secondary to
vasodilatation related to rewarming.
Discontinue potassium infusions.
The goal after rewarming is normothermia (ie,
avoidance of hyperthermia)
46. PHYSIOLOGIC EFFECTS AND
COMPLICATIONS
All complications infrequent
Shivering
Arrhythmias
Hyperglycemia
Electrolyte disorders
Coagulopathy
Alterations in drug metabolism
Risk of Infections
Cold diuresis
47. Shivering management
Shivering - body’s attempt at maintaining temperature
Major concern when trying to achieve a hypothermic state.
Shivering is uncomfortable, and generates heat and is
therefore counterproductive to targeted temperature
management.
Meperidine (50 mg IV q 6 hrs)
Buspirone (30 mg po q 8 hrs)
Sedation (midazolam, fentanyl, propofol, lorazepam)
Neuromuscular blocker (vecuronium 0.1 mg/kg bolus;
cisatracurium infusion 0.15 mg/kg bolus followed by 1-10
mcg/kg/min infusion)
Neuromuscular blocker can hide seizure activity,
Rapid on off sedation medications are preferable to permit
serial neurological assessment.
48. More experience needed…
OTHER INDICATIONS
TBI -Shown to be effective in traumatic brain injury with high ICP.
Refractory intracranial hypertension in new born
Acute stroke
PREHOSPITAL COOLING
Originally thought to improve outcomes,
To date, no cooling manoeuvres begun in the prehospital period have
improved neurologic recovery or mortality in several trials
One study noted - increased pulmonary oedema and repeat cardiac
arrest with 2 L of cold intravenous fluids.
COOLING VARIABLES
Timing of the initiation of cooling, cooling technique, rate, depth, and
length of cooling and rewarming all have some effect on mortality and
morbidity
These variables are not well studied & no head to head comparisons
Might be having different levels of importance on the basis of clinical
indications.
49. SUMMARY
Cool early (in the emergency department).
Use any cooling method but temperature strictly
monitored & for induction combination of methods
required.
Patients can continue to be cooled during percutaneous
coronary intervention (PCI).
Tight glycemic control, vigilance for signs of infection,
maintain perfusion, and use pressors if necessary
Practice standard neuroprotective strategies
Rewarming should be slow.
Predict and be proactive regarding management of
complications from ROSC and hypothermia