Transcript Document

Good Samaritan Hospital Hypothermia Therapy :
A New Frontier in Reducing Morbidity and Mortality in the
Post-Cardiac Arrest Patient
Missi Chittum RN, BSN
Vickie Wolnitzek RN, BSN
Scope of the Problem:
• Sudden cardiac arrest (SCA) is a leading cause of death in
the US
• Approximately 295,000 US out-of-hospital arrest per year
• Less than 10% of people who present to the hospital survive
to discharge
• Up to 65% initially comatose survivors suffer debilitating
neurological outcomes
Roger VL,Go AS, Lloyd-James DM, et al. Heart disease and stroke statistics-2011 update: a report from the American Heart Association Statistics .
CIRCULATION. 2011:123(4)c18-c209.
What is Mild Therapeutic
Hypothermia?
• Clinically induced hypothermia 32-34 degrees for 12-24
hours within 4 to 8 hours of spontaneous circulation
(ROSC)
• Evidence based care
• Brain-protective treatment to prevent/reduce reperfusion
injury following cardiac arrest and return of circulation
• Improves chance for good neurological outcome
AHA Guidelines for Cardiopulmonary Resuscitation and Emergency CV Care. Part 9. CIRCULATION 2010
History of Therapeutic
Hypothermia
• 1950s: First described but with no formal testing
• 1960s: Temperature targets were 28-32°C and research
findings were not favorable
• 1980s: Revival of interest using dogs after cardiac arrest
with temperature targets of 32-34°C had positive
outcomes
• 1990s: Therapeutic hypothermia was revisited:
 Can we safely cool patients?
 What is the best cooling method?
• 2000s: Using evidence based practice from prior
research trials
Evidence Based Research:
1. Dr. Bernard’ s study- one of the first
2. Mauro Oddo study –appropriate temperature range
3. HACA- a larger group of people with positive
outcomes
4. Sebastian Wolfrum- showed it was possible to
Hypothermia Therapy along side PCI despite
the higher risk of bleeding with anticoagulants
Dr. Bernard’s Study
• European study
• Decrease in mortality and
improved neurological outcomes
• 77 patients
- 43 hypothermia
- 34 normothermia
• Results
-49% of hypothermic patients had good outcomes
compared to 26% normothermic patients
Bernard SA, et al. “Treatment of comatose survivors of out-of-hospital cardiac arrest with induced
hypothermia.” NEJM 2002; 346 (8): 546-556.
Mauro Oddo:
• Researcher Mauro Oddo
• Implementation Study
 109 comatose out of hospital arrests
 Retrospective
 Determined feasibility of Therapeutic Hypothermia
(TH) to 33 degrees C in clinical practice
 VF as initial rhythm
 Good outcomes: TH 56% , standard care 26%
• TH safely applied to patients with initial rhythm of PEA
and asystole. Outcomes were poor, though the subset
was small
Oddo M. et al. from evidence to clinical practice : Effective implementation of therapeutic hypothermia to improve patient
outcome after cardiac arrest. Critical Care Medicine 2006: 34 (7): 1865-1873
HACA Study (Hypothermia After
Cardiac Arrest)
Multi-center trial
• 275 patients
- 137 Hypothermia
- 138 Normothermia
Results
- 55% Hypothermia group favorable outcome
- 39% Normothermia group favorable outcome
The Hypothermia After Cardiac Arrest Study Group. “Mild therapeutic hypothermia to improve the
neurologic outcome after cardiac arrest.” NEJM 2002 ; 346 (8): 549-556.
Wolfrum German Study
• Objective: Is it feasible, safe, and beneficial to combine
hypothermia therapy with percutaneous
intervention(PCI)?
• Patients: 33 cardiac arrest w/ v-fib, ROSC, unconscious
, and with acute ST elevation MI (STEMI)
• Results:
1.Did not result in longer door-to-balloon times
2.Target temp was reached w/i 4 hours
3.No increase in bleeding complications &
infections
4.Trend toward lower mortality (25% vs 35%)
5.Improved neurologic outcome
AHA 2010 Post Arrest
Guidelines
1. Post VF arrest patients who are unresponsive with a ROSC
after 0ut-of-hospital cardiac arrest should be cooled to:
1.32 ° C to 34 °C
2.Duration of 12-24 hours
2. Therapeutic Hypothermia (TH) may also be considered for
comatose adult patients with ROSC after initial rhythm is
PEA or asystole
3. Therapeutic Hypothermia can be considered for in-hospital
arrests
4. Transport patients to appropriate hospitals that can manage
and implement post cardiac arrest care to include TH
Pathophysiology…
• Cardiac arrest = No blood flow to the brain
• Depletes brain O2 stores within 20 seconds
• Results in irreversible brain damage if circulation is not
restored.
• Research has proven that it is not the lack of oxygen
during the arrest that causes brain death, yet it is the
release of oxygen free radicals into the brain that
causes post cardiac arrest brain injury when circulation
is restored
More Pathophysiology…
Benefits of Therapeutic
Induced Hypothermia
• Cerebral metabolism will decrease by 5%-7%for every
1° C reduction in core body temperature (Oku et
al.,1993)
• Reduces intercellular acidosis
• Decreases the inflammatory response and cytokines
release
• Protects the blood brain lipomembranes
Complications of Therapeutic
Hypothermia
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Depressed myocardial function
Dysrhythmias
Coagulopathy
Immunosupression
Fluid and electrolyte imbalances
Slow drug metabolism
Inclusion Criteria
• Post cardiac arrest
(VF/pulseless VT)
• Witnessed arrest
• Time of collapse to
ROSC <30 minutes
• Initiation of therapy within
6 hours of arrest time
• Initial temperature > 30
degrees C
• No command following
• NO level of brain death
precludes cooling
Exclusion Criteria
• DNR, terminal illness,
poor baseline function
• Hemorrhagic CVA, status
epilepticus
• Active severe bleeding
• Trauma until ruled out
• MAP < 60 mmHg for > 30
mins and requiring > 1
pressor
• Uncontrolled cardiac
arrhythmias
• History of
Cryoglobulinemia
• Pregnacy
The most important exclusion to remember
is…
Don’t chill the awake and talking
patient!
Please don’t
freeze
me!!!
Key Clinical Priorities:
Pre-Induction Phase
(Time Sensitive)
• Confirm witnessed v-fib arrest
• EMS-consider transporting patient to hospital with
hypothermia therapy
• Determine ROSC time
• Patient not responsive and following commands
• Initiate cooling- mechanism dependent on where patient is
• EKG – AMI requiring PCI
• Record Glasgow Coma score
Key Clinical Priorities:
Induction Phase
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Head CT
Record an initial temperature- rectal the best
Central line placement
Continue cooling method
Baseline labs
Initiate sedation/paralytic meds
Shivering
Transfer to appropriate critical care unit
Key Clinical Priorities:
Maintenance Phase
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Focus on cardiac & cerebral resuscitation
Nursing care 1:1
Maintain existing cooling methods
Use hospital approved cooling method and temperature
monitoring device
• Monitor patient for side effects and complications
Importance of Rewarming
Phase…
• Rewarming should occur at 0.3 to 0.5 °Celsius per hour
• Avoid complications of rapid rewarming, i.e. dangerous
electrolyte shifts and rebound hyperthermia
• Monitor lab values: K+ will increase & glucose decrease
• Discontinue sedation and paralytics once goal temp is
achieved
Physiologic Effects of
Hypothermia Therapy by
Body Systems
Cardiovascular
• Ventricular arrhythmias- atrial and ventricular fibrillation
• Myocardial depression, bradycardia, AV block
• Increased SVR, decreased CO, decreased contractility
Respiratory
• Decreased RR
• Hypoventilation
• Suppression of cough and mucociliary reflexes from
hypothermia therapy may lead to hypoxemia,
atelectasis, and pneumonia
• Shift in oxyhemoglobin dissociation curve to the left (less
oxygen is released from oxyhemoglobin to the soft
tissues)
Metabolic
• Hypothermia will cause glucose levels to elevate
• When shivering is allowed, there is an increase in
glucose utilization and levels then can remain NORMAL
• Yet shivering increases the metabolic rate, CO2
production and O2 consumption and myocardial work
• Slowed drug metabolism
Gastrointestinal
• Decreased motility, liver function,
• Ileus
• Stress Ulceration
Renal
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↑ urine output
↑ loss of electrolytes
↓ creatinine clearance
Tubular dysfunction
Electrolyte Shifts
• Find graph/picture
Hematologic
• Increased blood viscosity (hemoconcentration)
• Platelet dysfunction
Cooling methods…
• Initiate quickly as possible w/ goal to reach temperature
6 hours after ROSC
• Goal: 33°C / 91.4°F
• Period of 24 hours once goal temp is achieved
Cooling Methods
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Surface cooling with ice packs
Surface cooling with cooling blanket
Cool room
Fan
Moist towels and exposed skin
Use your hospital approved
cooling device
Other Methods of Cooling:
• Internal cooling with infusion of cool IV fluids
• Internal cooling with gastric lavage of iced saline
Cooling Blankets:
Cooling
Blanket
Thermo regulates
to preset patient
goal temperature
33° C with the use
of a rectal or
esophageal probe
Cooling Method: Endovascular
Device
Core Cooling Methods
Pharmacological Agents for
Prevention of Shivering
Nursing Care
Interdisciplinary Collaboration
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Champions
Pre-hospital care
ER
Cath Lab
Intensivists
Cardiologists
Pharmacy
Critical Care Units
Family
Lessons Learned
Starting a Program
Usman Omar.8 Key Principes for Success. Muslim Strategic Initiative 2011
Successes
What Does The Future Hold?
1. Research using the new sophisticated internal and
external cooling devices
2. Increased research to determine the optimal time to
target temperature and the rates of cooling and
rewarming
3. Future advances will require earlier initiation of therapy
either prior to cardiac arrest or during CPR
4. Hydrogen sulfide to induce a hibernation-like state in
animals seems to hold promise
Concluding Thoughts…
• Studies have shown that only 6 patients need to receive
therapeutic hypothermia for 1 life to be saved.
• The ONLY supportive therapy for favorable neurological
outcomes after an arrest
• The faster hypothermia therapy is induced, the better
the outcomes
• Cool them down instead of warm them up
Hypothermia Therapy:
COOL MEDICINE… Are you doing it?
References
Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-ofhospital cardiac arrest with induced hypothermia. N Eng J Med 2002; 346(8):557-563.
Nair SU, Lundbye JB. The use of hypothermia therapy in cardiac arrest survivors. Therapeutic Hypothermia and Temperature
Management 2011; 1(1):9-21.
Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after
cardiac arrest. N Eng J Med, Feb 21 2002. 346(8): p. 549-56.
Peberdy MA, Callaway CS, Neumar RW, et al. Part 9:post-cardiac arrest care: 2010 American Heart Association Guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122(18 supp 3):S768-S786.
Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009; 37(supp
7):S186-S202.
Harden J. Take a cool look at therapeutic hypothermia. Nursing 2011. 2011;41(9):p 46-51.
Oddo M, Schaller MD, Feihl F, Ribordy V, Liaudet L. From evidence to clinical practice: effective implementation of
therapeutic hypothermia to improve patient outcome after cardiac arrest. Crit Care Med. 2006 Jul; 34(7):1865-73.
Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics-2011 update: a report from the American Heart
Association Statistics. Circulation. 2011; 123(4):c18-c209.
Bahrt G. Cooler heart, better odds: Induced hypothermia. Nursing Management. 2009 Jul; 40(7):22-29.
Oku K, Sterz F, Safar P, Johnson D, Obrist W, Leonov Y, Kuboyama K, Tisherman SA, Stezoski SW. Mild hypothermia after
cardiac arrest in dogs does not affect postarrest multifocal cerebral hypoperfusion. Stroke 1993:24:1590-1597
Hypothermia cooling techniques. Resuscitation Central. Online 12 November 2011.
Wolfrum S. Pieerau C, Radke PW, Schnkert H, Kurowski V. Mild therapeutic hypothermia in patients after out of hospital
cardiac arrest due to accute ST elevation myocardial infarction undergoing immediate percutaneous coronary intervention
Crit Care Med 2008 Jun;36(6):1780-6