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

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. Scope of the Problem:

What is Mild Therapeutic Hypothermia? Clinically induced hypothermia degrees for 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):

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):

HACA Study (Hypothermia After Cardiac Arrest) Multi-center trial 275 patients Hypothermia 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):

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 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 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency CV Care. Part 9. CIRCULATION 2010

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 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 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 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 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 ↑ 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 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 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-of- hospital cardiac arrest with induced hypothermia. N Eng J Med 2002; 346(8): 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 (8): p 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 ;41(9):p 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 Jul; 34(7): 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 Jul; 40(7): 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: Hypothermia cooling techniques. Resuscitation Central. Online 12 November 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