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The hospital I work at recently (12/2009) started to offer Therapeutic Hypothermia as a therapy for patients post sudden cardiac arrest (SCA), and patients who had a return of spontaneous circulation (ROSC)./nIt has been an exciting couple of months of inservices, and clinical practice. To me it was like learning CPR all over again! I had learned CPR at the age of 14 because I wanted to help save lives. Now I can try to save more lives with therapeutic hypothermia. I'm still excited! Hope the thought of therapeutic hypothermia and/or this power point excites and inspires you.

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Therapeutic hypothermia

Therapeutic Hypothermia

Ralph Quinones

Grand Canyon University

NRS410V

January 17, 2010

[email protected]


Contents
Contents

Therapeutic Hypothermia (TH) Time Line

Sudden Cardiac Arrest (SCA) Statistics

Basic Pathology of SCA

Advantageous Effects of Therapeutic Hypothermia (TH)

Other Effects of Therapeutic hypothermia

TH Mortality Results and Outcomes

TH Impacts on Nursing


Therapeutic hypothermia th time line
Therapeutic Hypothermia (TH) Time Line

In 1803, Russians attempted to use hypothermia therapeutically when they covered patients with snow in an attempt to resuscitate them (Liss, 1981).

In the late 1930’s, hypothermia was studied in cancer patients with the hope that it would slow the division of cancer cells (Smith & Fay, 1940).

1959, the first study that addressed TH in cardiac arrest patients was published (Benson, Williams, Spencer, & Yates, 1959).

Studies slowed down until the 1990’s (Koran, 2009).

In 2003 the International Liaison Committee on Resuscitation adopted recommendations for the use of TH (Pyle, Pierson, Lepman, & Hewett, 2007).

“In Dec. 2005, to improve survival rates, the American Heart Association published resuscitation recommendations for using mild hypothermia”

(Pyle et al., 2007, P.32).


Therapeutic hypothermia th time line1
Therapeutic Hypothermia (TH) Time Line

In 2008 a handful of American cities incorporate TH protocols into their

Emergency Medical Services (EMS): Seattle, Boston, Miami, Vienna, and

London England (Hertocollis, 2008).

In Jan. 2009 New York City starts TH protocols and requires EMS to

transport, TH patients, to facilities practicing TH only (Hertocollis, 2008).

In December 2009 the City of Las Vegas adopted TH protocols into it’s EMS.

In December 2009 Valley Hospital, Las Vegas educates Emergency Room and

Medical Intensive Care Unit Personnel on TH.

In December 2009 Ralph Quinones states, “Therapeutic hypothermia is like

rediscovering CPR!” (J. R. Quinones, personal communication, December,

2009).

Jan. 2010 Ralph Quinones has participated in 3 TH therapies since Valley

Hospital initiated a TH protocol.


Sudden cardiac arrest sca statistics
Sudden Cardiac Arrest (SCA) Statistics

Each year in the United States of America:

310,000 people die of sudden cardiac arrest

375,000-750,000 people are resuscitated

About 40% of those resuscitated will have a return of spontaneous circulation (ROSC)

30% of survivors have severe brain damage

(Koran, 2009, P.49).

SCA 2004 survival rates (no TH):

8.4% for all cardiac arrests

17.7% for Ventricular-Cardiac arrest

(Pyle et al., 2007, P.32).


Basic pathology of sca
Basic Pathology of SCA

Immediate cessation of blood flow to the brain results in:

Decrease in cerebral oxygen

Neurons become hypoxic within 20 seconds

Central nervous system affected in first 5 min.

30% of cerebral blood flow is returned with CPR

Only 50% of cerebral blood flow returns within 12 hours of resuscitation

(Koran, 2009, P.49).


Basic pathology of sca1
Basic Pathology of SCA

Even after cerebral blood flow returns to baseline there is:

Generation of oxygen free radicals

Inflammatory cell invasion

Ion imbalances

Increased metabolic rate

Increase in cellular oxygen demand

(Koran, 2009, P.49).


Basic pathology of sca2
Basic Pathology of SCA

The goal of TH is to preserve brain tissue, neurological function, and a productive life post cardiac arrest.

An unknown source stated that 1:5 TH therapies preserve brain tissue and some function.

This unknown source also stated that 1:7 TH therapies preserve brain tissue, neurological function and a productive life post cardiac arrest.


Advantageous effects of therapeutic hypothermia th
Advantageous effects of Therapeutic hypothermia (TH)

TH counteracts some negative physiologic effects by:

Lowering body temperature

Decreasing metabolic demand

Decreasing cellular oxygen demand

Decreasing intracranial pressure: Vasoconstriction

Chronotropic effects

(Koran, 2009, P.49).


Other effects of therapeutic hypothermia
Other Effects of Therapeutic hypothermia

Decreased cardiac output/Cardiac index

Increased Systemic vascular resistance

Prolonger PR, QRS, and QT intervals

Decreased CO2 production

High risk for aspiration pneumonia

Slowed peristalsis

Diuresis

Impaired immune function

Impaired platelet function

Risk for skin injury

Electrolyte shifts

Hyperglycemia

Elevated lactate level

Shivering

Drug clearance is prolonged

(NLK & Valley Hospital,2009).


Th mortality results and outcomes
TH Mortality Results and Outcomes

In a randomized controlled trial of 275 patients

Hypothermia group

41% Mortality rate at 6 months

55% improvement in Neurologic outcome

Normothermia group

55% Mortality rate at 6 months

39% improvement in Neurologic outcome

(Pyle et al., 2007, P.33).


Th mortality results and outcomes1
TH Mortality Results and Outcomes

77 randomly assigned therapeutic hypothermia patients: Pre-hospital cardiac arrest survivors

Hypothermia group

  • 49% survival with good outcomes

    (Pyle et al., 2007, P.33).

Normothermia group

  • 26% survival with good outcomes

    (Pyle et al., 2007, P.33).


Th impacts on nursing
TH Impacts on Nursing

Theoretically, TH protocols can be started by EMS in the field or in the emergency room, ideally, the patient should be in mild hypothermia (33*C) within an hour of arrest. However, the optimal time to start TH is within the first five hours post SCA (Hertocollis, 2008).

Therapeutic hypothermia is achieved with Mild hypothermia (32-34*C).


Th impacts on nursing1
TH Impacts on Nursing

Identifying the indications and contraindications

Differentiate the methods for inducing mild TH

Safety issues and risks for mild TH

Appropriate care for patients receiving TH after SCA

(Pyle et al., 2007, P.33).


Th impacts on nursing2
TH Impacts on Nursing

Indications:

  • SCA with ROSC

  • 18 years or older

  • Persistent coma

  • No eye opening to pain

  • No response to tactile stimuli

  • Glasgow Coma Scale (GCS) < 8

  • SBP>90 mmHG with or without fluids and vasopressors

    (Valley Hospital, 2009).

Contra Indications:

Pregnancy

Severe coagulopathy

Other causes of coma

Pediatrics

Trauma

(Valley Hospital, 2009).


Th impacts on nursing3
TH Impacts on Nursing

Maintain

Temperature @ 33*C (91.4*F) X 24 hours

SBP > 90 mmHG

MAP > 80 mmHG

Sedation & Paralysis

Re-warm @ 0.3-0.5*C per hour X 12 hours

Central line access

Monitor

Temperature via Foley

For hypokalemia during cooling

For hyperkalemia during re-warming

Ramsey Sedation Scale

Bispectral Index (BIS)

(Valley Hospital, 2009).


Th impacts on nursing4
TH Impacts on Nursing

Bispectral index (BIS) is “no longer used only in the OR.BIS monitoring can now be used to help ensure that a patient is sedated safely and effectively”

BIS index is a measure of hypnotic effects of sedatives and anesthetics on the brain through EEG data.

The BIS works on a scale of 0-100, where 0=no brain activity, 100=awake and alert, and with a BIS <60 a patient is not likely to be awake

(Luebbehusen, 2005).


Th impacts on nursing5
TH Impacts on Nursing

With EMS protocols in place mild hypothermia is achieved within one hour of SCA and ROSC by:

Early CPR

Early Defibrillation

Intubation, sedation & paralysis

EMS placing ice packs at pressure points (Auxillary, femoral, etc…)

Cold (4*C) normal saline infusion of 30 ml/kg (max 4 liters) wide open, or in a pressure bag

Foley catheter with thermometer

Cooling blanket to maintain mild hypothermia


References
References

Benson, D. W., Williams, G. R., Jr., Spencer, F. C., & Yates, A. J. (1959). The use of hypothermia after cardiac arrest. Anesthesia & Analgesia, 38, 423-428.

Hertocollis, A. (2008, December 4). City pushes cooling therapy for cardiac arrest. The New York Times, pp. Unknown.

Koran, Z. (2009). Therapeutic hypothermia in the post-resuscitation patient: The development and implementation of an evidence- based protocol for the emergency department. Journal of Trauma Nursing, 16(1), 48-57.

Liss, H. P. (1981) A history of resuscitation. Annals of Emergency Medicine, 15, 65-72.

Luebbehusen, M. (2005). Technology today: Bispectral index monitoring [Online exclusive]. RN Web. Retrieved Unknown, from Unknown


References1
References

NLK, & Valley Hospital, (2009). [Medical cardiac ICU therapeutic hypothermia: Physiologic changes and nursing considerations]. Unpublished raw data.

Pyle, K., Pierson, G., Lepman, D., & Hewett, M. (2007). Keeping cardiac arrest patients alive with therapeutic hypothermia: How to develop a successful protocol. American Nurse Today, 2(7), 32- 36.

Smith, L. W., & Fay, T. (1940). Observations on human beings with cancer maintained at reduced temperatures of 75-90* Fahrenheit. American Journal of Clinical Pathology, 10, 1-11.

Valley Hospital, (2009). [ED therapeutic hypothermia nursing pathway]. Unpublished raw data.


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