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Targeted temperature management in cardiac arrest

Targeted temperature management in cardiac arrest. Cody M. Yochum, DNP, ARPN, FNP-BC, ENP-BC, CCRN Internal/Critical Care Medicine St. John Medical Center | Tulsa, Oklahoma. Targeted Temperature Management.

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Targeted temperature management in cardiac arrest

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  1. Targeted temperature management in cardiac arrest Cody M. Yochum, DNP, ARPN, FNP-BC, ENP-BC, CCRN Internal/Critical Care Medicine St. John Medical Center | Tulsa, Oklahoma

  2. Targeted Temperature Management • Targeted Temperature Management (formerly Therapeutic Hypothermia) is the intentional cooling of a patient to 33-36oC for 18-24 hours post-cardiac arrest. • Multiple studies have shown induced therapeutic hypothermia improves neurologic function in post-cardiac arrest patients when initiated within six hours of the arrest; starting with two landmark studies in 2002. • The American Heart Association in 2005 listed induced hypothermia as one of the guidelines for post-cardiac arrest care.

  3. How Does It Work? • Initial neurologic injury occurs when circulatory collapse impairs oxygen flow to the brain. Without oxygen, the brain switches to anaerobic metabolism, resulting in excessive calcium and glutamate excretion. This makes brain cells more excitable, leading to further hypoxemia, in turn causing mitochondrial and cellular death.  • Cellular death results in cerebral edema, producing further damage. • The initial injury also disrupts the blood-brain barrier, which increases fluid in the brain and worsens cerebral edema. • Hypothermia counteracts neuro-excitation in brain cells by stabilizing calcium and glutamate release, reducing the degree of cell death. It also stabilizes the blood-brain barrier and suppresses the inflammatory process, reducing cerebral edema. Cerebral metabolism decreases 6% to 10% for every degree Celsius that body temperature drops. As cerebral metabolism declines, the brain needs less oxygen. • Hypothermia counteracts many of the destructive mechanisms of cardiac arrest. Similarly, hypothermia halts destructive brain mechanisms and lets the brain reset itself to normal functioning. • Decard & Ebright (2011).

  4. Targeted Temperature Management Review • Two Landmark Studies • Holzer (2002) concluded therapeutic hypothermia results in a significant increase in the rate of a favorable neurologic outcome and reduced mortality in those who were successfully resuscitated after cardiac arrest due to ventricular fibrillation. • Bernard et al. (2002) concluded that treatment with moderate hypothermia appeared to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest • Lundbye (2012) conducted a study suggesting therapeutic hypothermia is associated with favorable neurologic outcome and survival in patients resuscitated after cardiac arrest due to non-shockable rhythms including asystole and pulseless-electrical activity. • Dumas et al. (2011) performed a study that concluded hypothermia was independently associated with an improved outcome at hospital discharge in patients presenting with a shockable rhythm, but was not associated with good outcome in nonshockable patients. • 2015 guidelines of post-cardiac arrest care by the American Heart Association amended its recommendations, adding all comatose patients with return of spontaneous circulation should receive therapeutic hypothermia regardless of initial rhythm (Callaway et al., 2015).

  5. Targeted Temperature Management Review • After cardiac arrest and successful resuscitation, patient can be determined if he/she is a candidate for TTM • Several Inclusion & Exclusion Criteria • Multiple Cooling Methods • Ice Packs • Cooled Saline • Gaymar Unit • Zoll Catheter • Cooled for 24 hours • Slowly rewarmed • Neurological Function assessed

  6. Targeted Temperature Management Review • Multiple studies have been published suggesting early initiation and fast achievement of therapeutic hypothermia is associated with better neurologic outcomes (Testori et al., 2014; Wolff et al. 2009). • Targeted Temperature Management has no effect on cardiac function, only neurologic. • Studies suggest that initiation in the emergency department gives patients a possible advantage for better recovery (Castelblanco, 2011). • Bigham, Dainty, Scales, & Brooks (2009) published a study showing hypothermia has been shown to improve neurologic outcomes, but application rates are less than 30%. • Critical Care Medicine journal published a study on perceived barriers in therapeutic hypothermia care. Lack of education and awareness were listed as barriers (Toma et al., 2009).

  7. Bottom Line

  8. Targeted Temperature Management

  9. How It Works…

  10. Cardiac Arrest • Full Advanced Cardiac Life Support Measures • Intubation • CPR • Defibrillation • Medications • Epinephrine • Bicarbonate • Amiodarone • Correct Abnormalities • ABG; pH • Acidosis • Electrolytes • Hemodynamic Support • Pressors; Inotropes, etc.

  11. Return of Spontaneous Circulation • Maximize Hemodynamic & Respiratory Support • Vasopressors Support • Hyperventilation? • Baseline Assessment • Neuro-Assessment • Purposeful Movements? • Paralytics/Sedation • Vitals • Respiratory Effort • Labs! • Initial Rhythm • V-Fib/V-Tach: Immediate Cardiac Consultation • Further/Immediate Intervention? • Cardiac Cath? • Pulmonary Embolism? • Pan-Scan

  12. Targeted Temperature Management Inclusion Criteria Exclusion Criteria ROSC >6hrs Prior GCS >8; Purposeful Movements Initial Temp <30 MAP <60 with Interventions Terminal Illness DNR Standing Coagulopathy/Active Bleeding Primary Intra-Cranial Event Arrest Secondary to Severe Sepsis Major Surgery in last 72 Hours Trauma Patient at Risk for Bleeding • Cardiac Arrest/ROSC within 6 Hours • GCS <8 • SBP ~90 • Mechanical Ventilation • >16 Year Old Patient

  13. Alternative Targeted Temperature Management: 36 Degrees • Mild Hypothermia/Normothermia for Excluded Patients • Inclusion: • Mild Coagulopathy (Platelets <30,000 or 30,000-50,000) • Pregnant with OB Consult • Complications (Hypotension, Arrhythmias) • Sepsis/Severe Sepsis

  14. Start The Cooling! • Once patient has been determined eligible for TTM: • Immediately place ice packs to axilla, neck, and groin region • 2L Cooled Saline Infusion • Post-Arrest Labs • ABG • CBC, Chemistry + Mag + Phos • Coags • Cardiac Enzymes • Lactate • Blood Cultures x 2 • Arterial Line Placement • Central Line or Invasive Cooling Line Placement • Internal Temperature Probe • Esophageal Temperature Probe • Foley Probe (Unless Urine Output <4ml/hr) • Rectal Probe

  15. Don’t Wait!!! A large study by Sendelbach et. al (2012) concluded the odds of poor neurological outcome increased with each 5-minute delay in initiating therapeutic hypothermia treatment, and the delay in initiation of cooling measures led to a delay in time to target temperature, of which the study states increases chances of poor neurological outcome for every 30 minute delay in time to target temperature. Yochum & Utley (2016) found creation of an Emergency Department TTM protocol decreased time of initiation from 127.8 minutes to 15.71 minutes.

  16. Invasive Cooling Methods • Gaymar Surface Cooling • ZOLL Cooling Catheter • IV Fluids • Blanketroll II

  17. Best Temperature? • No Definitive Targeted Temperature • Research Cases Range from 33-36 Degrees Celsius • Nielsen et al. (2013) conducted a study evaluating targeted temperature management at 33 degrees versus 36 degrees, and found no significant difference in outcomes or benefits. • The American Heart Association in its 2015 Advanced Cardiac Life Support guidelines modified its therapeutic hypothermia guidelines, stating “we recommend selecting and maintaining a constant temperature between 32oC and 36oC during targeted temperature management” (Callaway et al., 2015).

  18. Targeted Temperature Management • Best if obtain goal temperature in <4 hours from ROSC • Temperature: 34-36 Degrees • Assess for Shivering Every Hour • Acetaminophen, Buspirone, Fentanyl, Meperidine, Propofol, Cisatracurium • Supportive Therapy • Maintain MAP >80 & CVP 8-12 • Strict Intake/Outputs • Frequent Vitals: Q15Min • Medications & Electrolytes • Analgesia, Sedation, & Famotidine • Glucometer, Insulin Drip. Maintain Glucose <200 • Potassium ~3.3 • Magnesium >2.0 • Labs • Chemistry 8, ABG, Magnesium, and PT/PTT/INR Every 6 Hours

  19. Adverse Effects Unable to reach target temp within 4 hours Urine Output <0.5mL/kg Resistant Shivering MAP < 80 and/or CVP < 8 Serum K+ > 5.0 Arrhythmias Seizure/Posturing Worsening Coagulopathy

  20. Neurologic Prognosis • Cannot be determined until: • Patient Completely Rewarmed • Paralytics Have Metabolized based on Train of Four • Sedation Weaning/Metabolization • EEG • Continuous versus Regular • Diagnostic Imaging • MRI • CT Head

  21. Rewarming • Begins 24 hours after achieving goal temperature • Re-warm at rate of 0.25 degrees until reaches 36 degrees • Turn off Paralytics • Begin Weaning Sedation/Analgesia • Monitor for hypotension and hyperkalemia • Warming may take up to 12 hours • Leave Temperature Control device in place to prevent rebound hyperthermia

  22. Statistics According to AHA 2015 Heart & Stroke Statistics (Mozaffarian et al. 2015): Incidence of out-of-hospital cardiac arrest is 326,200. Average survival rate is 10.6% Survival with good neurologic function is 8.3% In 2009, a review and compilation of recent experiences of therapeutic hypothermia after cardiac arrest was performed and published in Critical Care Medicine. The authors compiled protocol methodology from multiple hospitals and looked at survival-to-hospital discharge and neurological outcomes. The results confirmed hypothermia did maximize chances of a meaningful recovery. The findings showed the use of therapeutic hypothermia increased survival with an odds ratio of 2.5, and favorable outcome with an odds ratio of 2.5 (Sagalyn, Band, Gaiesky, & Abella, 2009).

  23. Conclusion

  24. References • Bernard, S., Gray, T., Buist, M., Jones, B., Silvester, W., Gutteridge, G., & Smith, K. (2002). Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. New England Journal of Medicine, 346(8), 557-563. • Bigham, B., Dainty, K., Scales., D., Brooks, S. (2010). Predictors of adopting therapeutic hypothermia for post-cardiac arrest patients among Canadian emergency and critical care physicians. Resuscitation, 81(1), 20-24. • Castelblanco, F. (2011). Effects of early initiation of induced therapeutic hypothermia. [Presentation]. Retrieved from http://www.aacn.org/dm/ntispeakermats/ posterdetails.aspx ?abstractid=00065919. • Decard, M.E. & Ebright, P.R. (2011). Therapeutic hypothermia after cardiac arrest. American Nurse Today, 6 (7), 23-28. • Dumas, F., Grimaldi, D., Zuber, B., Fichet, J., Charpentier, J., Pene., F., … Cariou, A. (2011). Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients? Circulation, 2011(123), 877-886. doi: 10.161/circulationaha.110.987347 • Holzer, M. (2002). The hypothermia after cardiac arrest study group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. The New England Journal of Medicine, 348(8), 549-556. • Lundbye, J., Rai, M., Ramu, B., Hosseini-Khalili, A., Li, D., Slim, H., Bhavani, S., Nair, S., & Kluger, J. (2012). Therapeutic hypothermia is associated with improved neurological outcome and survival in cardiac arrest survivors of non-shockable rhythms. Resuscitation, 83(2), 202-207. • Mozaffarian, D., Benjamin, E., Go, A., Amett, D., Blaha, M., Cushman, M., … Turner, M. (2015). Heart disease & stroke statistics; Circulation, 41. doi: 10.1161/CIR0000000000000152.

  25. References Continued • Nielsen, N., Wetterslev, J., Cronberg, T., Erlinge, D., Gasche, Y., Hassager, C., … Friberg, H. (2013). Targeted temperature management at 33oC versus 36oC after cardiac arrest. The New England Journal of Medicine, 369, 2197-2206. doi: 10.1056/nejmoa1310519 • Sagalyn, E., Band, R., Gaieski, D., & Abella, B. (2009). Therapeutic hypothermia after cardiac arrest in clinical practice: Review and compilation of recent experiences. Critical Care Medicine, 37(7), 223-226. • Sendelbach, S., Hearst, M., Johnson, P., Unger, B., & Mooney, M. (2012) Effects of variation intemperature management on cerebral performance category scores in patients who received therapeutic hypothermia post cardiac arrest. Resuscitation, 83(7): 829-834.doi: 10.1016/j.resuscitation.2011.12.026 • Testori, C., Stratil, P., Losert, H., Herkner, H., Holzer., M. … Sterz, F. (2014). Early initiation and fast achievement of mild therapeutic hypothermia in patients successfully resuscitated from out-of-hospital cardiac arrest. Circulation, 130, A325. • Toma, A., Bensimon, C., Dainty, K., Rubenfeld, G., & Morrison, L. (2009). Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: A qualitative study of emergency department and critical care workers. Critical Care Medicine, 38(2), 504-509. • Yochum, C. & Utley, R. (2016). Initiation of therapeutic hypothermia in the emergency department: A quality improvement project. Advanced Emergency Nursing Journal, 39(1): 52—58.

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