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THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARREST USING PERFORMANCE TARGETS. Raghu Loganathan, MD, FCCP Director, Medical ICU & Stroke Center March 2010. Disclosures. Nothing extraordinary in the case reports Use 2 case studies to describe successful implementation of a new protocol .

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therapeutic hypothermia for cardiac arrest using performance targets

THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARRESTUSING PERFORMANCE TARGETS

Raghu Loganathan, MD, FCCP

Director, Medical ICU & Stroke Center

March 2010

disclosures
Disclosures
  • Nothing extraordinary in the case reports
  • Use 2 case studies to describe successful implementation of a new protocol
cardiac arrest epidemiology
Out of Hospital cardiac arrests

64% of all arrests

2 to 9% survive to discharge

1/ 3rd of survivors have irreversible cognitive dysfunction

In-hospital cardiac arrests

36 % of all arrests

18% survive to discharge

Cardiac Arrest Epidemiology

ILCOR 2008 Circulation 2008; 118:2452-83

mild therapuetic hypothermia clincial studies
MILD THERAPUETIC HYPOTHERMIACLINCIAL STUDIES
  • RCT’s
    • Bernard S et al – NEJM 2002; 346(8)
    • Holtzer M et al – NEJM 2002; 346 (8)
    • Idrissi et al – NEJM 2001
  • Other Designs
    • Benson D et al – Anaes Analg 1959; vol 38
    • Bernard S et al – Ann Emerg Med 1997; 33(2)
    • Bernard S et al – Resuscitation 2003; 56(1)
  • Meta-analysis
    • Holtzer M et al – Crit Care Med 2005; 33(2)
summary of landmark trials
Summary of Landmark Trials

HACA study group, NEJM, 2002 & Bernard SA, NEJM 2002

mild therapeutic hypothermia fdny initiative
MILD THERAPEUTIC HYPOTHERMIAFDNY initiative
  • Less than 15% hospitals are currently using hypothermia in US
  • Designated hypothermia centers
    • Cardiac arrests triaged by EMS
  • Model based on STEMI/ PCI centers & Stroke Centers
case study 1
Case Study -1
  • 69 year old male progressively dyspenic for 5 days
  • EMS found him cyanotic
  • Initial PEA, followed by asystole and V fib
  • Intubated on the field
  • Downtime 26 minutes

PMH: HTN, COPD, CAD, Morbid Obesity

  • Arrived in ED comatose, GCS 3T
  • PAP 54 on ventilator
case study 18
Case Study -1
  • Cold saline: 4.5 liters started within 5 minutes
  • Surface cooling in 25 minutes
  • Central line placed 30 minutes
  • Initial Lactate was 9.3, ScVo2 65%
  • Baseline Temp was 37.2
  • Target temp reached in 3.4 hours
    • Double vests used in series
case study 19
Case Study -1
  • EKG: no STEMI
  • Mild elevation of troponins
  • ECHO showed depressed EF (30%) with wall motion abnormalities
  • CXR showed lower lobe infiltrates
case study 110
Case Study -1
  • Posturing with de-cerebrating signs noted at 5 hours
  • TH continued with sedation and paralytics for shivering
  • Re-warming after 24 hours
  • EEG showed diffuse slowing, no seizures
  • No clinical response when sedation was stopped
  • Day 3; spontaneous eye opening and followed some commands
  • Day 6 Able to follow more commands
case study 111
Case Study -1
  • Day 9: Unable to extubate transferred to vent floor
  • Day 17 Trach done
  • Day 23 weaned off Trach
  • Day 25 discharged to SNF
  • March 25th: Trach de-cannulated, ambulating and functioning at baseline
case study 2
Case Study : 2
  • 72 year old male well known to Lincoln BIBEMS
  • ESRD, Known asthma, Known CAD
  • EMS called for respiratory distress, “noted to hypotensive and dyspneic and went into cardiac arrest”
  • “Wide QRS on 3 lead” placed on NRB
  • Subsequently “patient agonal, PEA on monitor, 3 blocks from hospital, CPR started immediately”
  • ED arrival 10 minutes later: CPR continued
  • Intubated in ED, various rhythms, 2 doses of epinephrine and atropine given
case study 213
Case Study : 2
  • Post intubation, noted to be “de-cerebrating” by ED attending
  • ROSC at 25 minutes:BP 143/ 76, RR 20 at set rate and Pulse 67
  • MICU called for therapeutic hypothermia
    • Unresponsive to deep stimuli, comatose
  • Hypothermia initiated 40 mins after ROSC
  • Myoclonic jerks observed day 1
  • 36 hours into protocol: patient opens eyes and following simple commands
who to cool inclusion criteria
Who to Cool?Inclusion Criteria
  • Post-cardiac arrest: defined as absence of pulses requiring chest compressions, regardless of location or presenting rhythm
  • Any Initial rhythm (VF/VT, asystole or PEA)
  • ROSC within 30 minutes to a SBP > 90 mmHg (with or without vasoactive meds)
  • Patient is comatose (unable to follow commands/ GCS < 6) upon arrival to the hospital in the absence of sedation
  • Time at start of cooling is within 4 hours after ROSC
who to cool exclusion criteria
Who to Cool?Exclusion Criteria
  • Another reason to be comatose
  • Purposeful response to verbal commands or noxious stimuli after ROSC and prior to initiation of hypothermia
  • Absent brainstem function not explained by treatment with sedatives, paralytics or anti-cholinergic agents
  • A known terminal illness preceding arrest
  • ? Pregnancy ( Case report showing benefit)
who to cool exclusion criteria16
Who to Cool?Exclusion Criteria
  • Pre-existing DNR and / or DNI code status and patient not intubated as part of resuscitation efforts
  • Multi-organ system failure, refractory shock requiring high doses of vasopressors (MAP<60 on 2 or more vasopressor agents), severe persistent hypoxia, acidosis or co-morbidities with minimal chance of meaningful survival independent of neurological status
  • Uncontrolled bleeding to coagulopathy
  • Recurrent VF or refractory VT in spite of appropriate therapy should generate consideration of emergent referral for cardiac catheterization          
slide17

Aa

Typical Cooling and Rewarming Protocol

Aa

how to cool icu notification
How to Cool?ICU Notification
  • Once eligibility for induced hypothermia is determined, call MICU/ Stroke attending ASAP
  • Obtain 2 large bore IV lines
  • Obtain baseline temperature
  • Infusion of approximately 2 to 3 liters (for 70 kg individual) of normal saline refrigerated at 4-5 °C
    • Can safely and reliably lower core body temperature by 3-4 °C when infused over 50 minutes.
cooling protocol
COOLING PROTOCOL
  • Obtain laboratory tests ASAP:
    • Beta HCG on all women of childbearing age
    • Arterial blood gas
    • CBC/ platelets / PT / PTT/INR, Fibrinogen
    • Electrolyte “panel 7”, plus iCa / Mg / Phos , Cl-, Glucose
    • Amylase, Lipase, LFTs, , Lactate, CPK-MB, CK, Troponin
    • Blood Cultures, Urine Cultures, Urinalysis
  • Toxicology screen if appropriate
  • 12 lead EKG, Chest X-ray
  • Placement of urinary catheter with temperature sensor
  • Insertion of Central Line Catheter (subclavian or IJ)
gaymar iii
GAYMAR III

Not selling this product

slide22

January 2009 to February 2010

58 cardiac arrest patients to ED

22 patients in ED with ROSC

18 INPATIENTS

screened

14 PATIENTS COOLED

12 INPATIENTS COOLED

clinical characteristics
Clinical Characteristics
  • 26 patients cooled
  • Rhythm:
    • Vtach/ Vfib = 3 patients
    • Asystole/ PEA = 18
    • Mixed (VF with asystole/ PEA) = 5 patients
  • Average APACHE II = 26 (predicted death rate of 64%)
  • 22/ 26 had 100% compliance with hypothermia bundle
  • Average ICU days on vent 7.03 days
outcomes
OUTCOMES
  • 26 patients cooled
  • 11/ 26 (42.3%) survived to hospital discharge
  • 10/ 26 (38.4%) had “good outcomes”
summary of studies
Summary of Studies

Neurologic

50%vs 14%

Neurologic

23%vs7%

Survival

50%vs 23%

Survival

54%vs 33%

Neurologic

49%vs26%

Neurologic

55%vs39%

Survival

48%vs 32%

Survival

59%vs 45%

slide27

Who to Cool ?

Does Rhythm Matter?

  • Data from RCTs”
    • Suggest VF and VT
  • Combination of rhythms during a cardiac arrest event
  • Underlying mechanisms of brain injury are same
  • Multiple observational trials on asystolic rhythm have shown benefit
who to cool do circumstances of arrest adequately predict outcome
Who to cool? Do Circumstances of Arrest Adequately Predict Outcome?

Practice Parameters: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation, NEUROLOGY 2006;67:203–210

complications
Complications

HACA study group, NEJM, 2002

summary
SUMMARY
  • Screening of patients:
    • Judgement improves with time
    • Rhythm alone should not exclude patients
      • Most have combined rhythms
      • Information on initial rhythm not always available
  • Use of bundles helps with rapid implementation and achieving target temp
    • Performance targets helps
future directions
FUTURE DIRECTIONS
  • Phase 2 FDNY hypothermia
    • Cool Enroute to hospital
  • MCA ischemic Infarcts
  • Traumatic brain injury
  • SAH patients with increased ICP
  • Hepatic encephalopathy