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Evidence-based Insights and Pathophysiology for

Evidence-based Insights and Pathophysiology for Targeted Temperature Management in Emergency Medicine and Critical Care. BMD/AS50/0417/0243. Why are we here today?. BMD/AS50/0417/0243. Disclosures.

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Evidence-based Insights and Pathophysiology for

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  1. Evidence-based Insights and Pathophysiology for Targeted Temperature Management in Emergency Medicine and Critical Care BMD/AS50/0417/0243

  2. Why are we here today? BMD/AS50/0417/0243

  3. Disclosures The speaker is a paid consultant of Bard Medical. This presentation contains the opinions and practices of the individual shown herein. The opinions presented herein do not represent the opinions of Bard Medical. Please consult Bard product labels and inserts for any indications, contraindications, hazards, warnings, cautions, and instructions for use. BMD/AS50/0417/0243

  4. Learning Objectives Upon completion of this module, the participant will be able to: • Recognize role of Targeted Temperature Management (TTM) • Review TTM evidence-based practice • Discuss patient management during TTM • Identifying and addressing shivering • Fever control BMD/AS50/0417/0243

  5. Targeted Temperature Management BMD/AS50/0417/0243

  6. Evolution in the TTM Field • 2010 Field, et al. recommends that Comatose adult patients with ROSC should be cooled to 32°C to 34°C for 12 to 24 hours Field, JM. et al (2010). Circulation. 122(18): S640-S664. BMD/AS50/0417/0243

  7. Evolution in the TTM Field • 2010 Comatose adult patients with ROSC should be cooled to 32°C to 34°C for 12 to 24 hours • 2015 All comatose adult patients with ROSC should have TTM… Field, JM. et al (2010). Circulation. 122(18): S640-S664. Neumar, RW. et al (2015). Circulation. 132: S313-S367. BMD/AS50/0417/0243

  8. What’s the latest news in the TTM field? • 2010 Comatose adult patients with ROSC should be cooled to 32°C to 34°C for 12 to 24 hours • 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32°C and 36°C selected and achieved… Field, JM. et al (2010). Circulation. 122(18): S640-S664. Neumar, RW. et al (2015). Circulation. 132: S313-S367. BMD/AS50/0417/0243

  9. Evolution in the TTM Field • 2010 Comatose adult patients with ROSC should be cooled to 32°C to 34°C for 12 to 24 hours • 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32°C and 36°C selected and achieved, then maintained constantly for 24 hours Field, JM. et al (2010). Circulation. 122(18): S640-S664. Neumar, RW. et al (2015). Circulation. 132: S313-S367. BMD/AS50/0417/0243

  10. Targeted Temperature Management (TTM) • Prescribed TTM includes dosage and duration • Current trends based on recent studies • 33°C - 36°C selected and achieved • 36°C • Hyperthermia control Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. BMD/AS50/0417/0243

  11. What’s the recent news in the TTM field? Select and Maintain • Specific conditions of the patient may favor selection of one temperature target over another • Allowing patients to warm above 36°C would be inconsistent with current TTM recommendations Neumar, RW. et al (2015). Circulation. 132: S313-S367. BMD/AS50/0417/0243

  12. Four Phases* Normothermia 37˚C 37˚C Induction Rewarm 0.25˚C / hour Maintenance 32˚C – 34˚C 32˚C – 34˚C 24 hours *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. BMD/AS50/0417/0243

  13. Four Phases* 72hrs Controlled Normothermia 37˚C 37˚C Normothermia Induction Rewarm 0.5˚ C / hour Maintenance 36˚C 36˚C 36hrs of Intervention 4+ Day Protocol *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. BMD/AS50/0417/0243

  14. Global Ischemia • Transient (5 – 30 minutes) complete or nearly complete lack of blood flow • Lack of blood supply leads to ischemia • If blood flow is not restored within 30 minutes, widespread necrosis occurs Polderman, KH. (2004). IntCare Med. 30(4), 556-575. BMD/AS50/0417/0243

  15. Focal Ischemia • Results from occlusion of a single cerebral blood vessel • Necrosis occurs near the occluded vessel if reperfusion does not occur within 60 min • Surrounding area (penumbra) may be salvaged if reperfusion occurs Polderman, KH. (2004). IntCare Med. 30(4), 556-575. BMD/AS50/0417/0243

  16. “preventing ischemic injury is central to all neuroprotective strategies” Polderman, KH. (2008). Lancet. 371, 1955-69. BMD/AS50/0417/0243

  17. Neuronal Damage from Ischemia • Complex negative cascade of reactions at cellular level • May begin minutes after injury and continue up to 72 hours or longer • Chain of events is called secondary injury or reperfusion injury Polderman, KH. (2008). Lancet. 371, 1955-69. BMD/AS50/0417/0243

  18. Ischemic Cascade1-3 • Mitochondrial dysfunction • Release of excitatory neurotransmitter glutamate • Excess release of calcium • Disruption of cell membranes • Free radical production • Blood brain barrier dysfunction Polderman, KH. (2008). Lancet. 371, 1955-69. Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. Malhotra, R. & Lee, K. (2012). The Neuro ICU Book. New York: McGraw Hill Companies, Inc. pp. 188-201. BMD/AS50/0417/0243

  19. 8 5 2 2 9 6 3 2 10 7 1 4 Alkadri, M. (2009). The Ochsner Journal. 9(4), 278-281. BMD/AS50/0417/0243

  20. Key Clinical Considerations* • Inhibit neurotransmitter release1 • Inhibit free radical production1 • Reduce oxygen consumption1 • Decrease cerebral metabolic rate (5 - 8% for every 1°C)1 • Preserve blood brain barrier integrity1 • ICP and cerebral edema are decreased2 • Consider the shivering threshold: dependent on patient’s thermoregulatory set point1,2 • Consider the reduction in cerebral metabolic demand1 • May be appropriate for patient population that cannot tolerate 33°C3 • Polderman, KH. (2008). Lancet. 371, 1955-69. • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. *Follow physician orders and / or your hospital’s policies and procedures for selecting target temperature BMD/AS50/0417/0243

  21. What’s the latest news in the TTM field? Prehospital Initiation Routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids is no longer recommended Neumar, RW. et al (2015). Circulation. 132: S313-S367. BMD/AS50/0417/0243

  22. Physiological Effects of Therapeutic Hypothermia* Cardiovascular • ↓ BP, HR, CO1-3 • EKG Changes • Prolonged PR interval1,2 • Widening QRS complex1,2 • Increased QT interval1,2 • J or Osborn wave1 *Representative of target temperatures 32 - 35°C Mehta, S. (2010). PA: HMP Communications. pp. 603-612. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. Tischerman, SA. & Stertz, F. (2010). New York: Springer Science. pp. 235-246. BMD/AS50/0417/0243

  23. Physiological Effects of Therapeutic Hypothermia* Cardiovascular J Wave or Osborn Wave *Representative of target temperatures 32 - 35°C PoldermanK. (2009). Crit Care Med. 37(7), S186-202. BMD/AS50/0417/0243

  24. Physiological Effects of Therapeutic Hypothermia* • Hematological1 • Impaired clotting cascade • Impaired platelet function: potential increase in bleeding risk • Decreased WBC count • Renal • ↑ Diuresis2,4 • Electrolyte loss3 • Gastrointestinal1 • Impaired bowel function / motility • Mehta, S. (2010). PA: HMP Communications. pp. 603-612. • Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. *Representative of target temperatures 32 - 35°C BMD/AS50/0417/0243

  25. Physiological Effects of Therapeutic Hypothermia* • Systemic • ↓ O2 consumption and CO2 production1,3 • Left shift on oxyhemoglobin curve: O2 is not readily released to the tissues4 • Lactic acidosis4 • Endocrine1,3 • ↓ Insulin secretion • Immune suppression1 • ↑ Infection: wound infections and pneumonia • Other1 • Shivering • Drug metabolism prolonged • Mehta, S. (2010). PA: HMP Communications. pp. 603-612. • Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. *Representative of target temperatures 32 - 35°C BMD/AS50/0417/0243

  26. Shivering • A physiological reflex mechanism that occurs when the body needs to produce or maintain heat • The primary center for shivering is found in the posterior hypothalamus Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. BMD/AS50/0417/0243

  27. Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5. BMD/AS50/0417/0243

  28. Shivering • Involuntary sympathetic response to generate heat4 • Vasoconstriction • Piloerection • Leads to increased:1-4 • Metabolic rate • Metabolic demand • Oxygen consumption • Carbon dioxide production • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. • Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0417/0243

  29. Shivering Management • Counter warming is the first line therapy for shivering treatment1 • Sedation prevents increased metabolism1 • Paralytic agents affect shivering1-3 Precautions: difficult to identify seizures, select agent with anticonvulsant properties, continuous EEG may be utilized, drug metabolism is affected, appropriate dosing must be tailored to the specific conditions of the patients and must be tightly monitored • Mehta, S. (2010). PA: HMP Communications. pp. 603-612. • Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. • Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. BMD/AS50/0417/0243

  30. Four Phases* Time to Initiation Normothermia 37˚C Induction Rewarm 0.25˚C / 16hrs Maintenance 32˚C – 36˚C 24 hours *Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. BMD/AS50/0417/0243

  31. Phases of Therapy Induction Phase • Careful monitoring of fluid balance • Glucose control • Monitor for hypertension • Electrolyte management • Prevention of shivering • General Considerations: This list may vary depending on the patient’s underlying condition. • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0417/0243

  32. Phases of Therapy Maintenance Phase • Maintain fluid status • Infection surveillance • Frequent electrolyte monitoring • Avoid hyperglycemia • Monitor for: • EKG changes • Bleeding • Skin changes • General Considerations: This list may vary depending on the patient’s underlying condition. • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Mehta, S. (2010). PA: HMP Communications. pp. 603-612. • Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0417/0243

  33. Phases of Therapy Rewarming Phase • Slow and controlled rewarming(0.1° – 0.5°C per hour) • Rapid rewarming may lead to a number of complications such as, but not limited to: • Hypoglycemia • Increased ICP • Rapid electrolyte shifts (hyperkalemia) • Sudden vasodilation • Cardiac arrest • General Considerations: This list may vary depending on the patient’s underlying condition. • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0417/0243

  34. Phases of Therapy Controlled Normothermia Phase • Fever during the first 72 hours after ROSC has been associated with poor outcome • Many clinicians attempt to maintain normothermia (36 - 37°C) during this time for at least 72 hours after ROSC General Considerations: This list may vary depending on the patient’s underlying condition. Seder, DB. & Van der Kloot, TE. (2009). Crit Care Med. 37(7): S212. BMD/AS50/0417/0243

  35. Neuroprognostication • TTM alters the ability to obtain a reliable neuro exam • Drug clearance is decreased so sedatives may be present up to 48-72 hours • Decisions regarding withdrawal of care must be delayed until adequate clinical exam can be performed • Follow your institution’s guidelines for prognostication • Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. • Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. • Blondin, NA., & Greer, DM. (2011). The Neurologist.17(5): 241-248. BMD/AS50/0417/0243

  36. List of References • Badjatia N (2006). CurrNeurolNeurosci Rep. 6(6): 509-517. • Badjatia NE, et al (2008). Stroke. 39(12): 3232-3247. • Choi A, et al (2010). Neurocrit Care. 14(3): 389-394. • Diringer MN, et al (2004). Crit Care Med. 32(7): 1489-1495. • English MJ & Hemmerling TM (2008). European J Anaesthesiology. 25(7): 531-537. • Greer DM, et al (2008). Stroke. 39: 3029-3035. • Mayer SA, et al (2004). Crit Care Med.32(12): 2508-2515. • Merchant R (2006). Crit Care Med. 34(12): S490-S494. • Nielsen N, et al (2013). N Engl J Med. 369(23): 2197-206. • Peberdy, et al (2010) Circulation. 122(18 Suppl 3): S768-S786. • Polderman K (2009). Crit Care Med. 37(7): S186-202. • Tomte O, et al (2011). Crit Care Med. 39(3): 443-9. BMD/AS50/0417/0243

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