Therapeutic Hypothermia Protocol for Brain Injuries

1. Therapeutic Hypothermia Protocol for Brain Injuries Paige Whitmire Dietetic Intern 2014-2015

2. Background Information • “Old” practice ideas to reduce ICP • Fluid restriction • Use of Mannitol (diuretic) • Hyperventilate (decrease CO2 levels) • No feeding due to glucose metabolism risk • “New” practices continue to be developed

3. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia’s impact on nutrition • My patient vs. current research • Nutritional assessment based on findings

4. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia’s impact on nutrition • My patient vs. current research • Nutritional assessment based on findings

5. Patient Selection • Learning about a new protocol • “Cutting edge” research • Opportunity to directly measure resting metabolic rate

6. Medical Diagnosis • Primary diagnosis: subarachnoid hemorrhage • Patient’s prognosis: poor • Hypothermia could improve outcomes?

7. Therapeutic Hypothermia • Cooling: obtained goal temperature in 7 hours • Method of Cooling: • External Cooling Gaymar Meditherm • Cooled to: 32.8◦C • Duration: 5 days hypothermic • Re-warming: 0.1◦Cper hour to 37.1◦C • Obtained in 25 hours

9. Medication/Paralytics • Paralytic • Vecuronium: 0.8 mg/kg/min • Sedatives • Midazolam: 0.7 mg/kg/hr • Fentanyl: 175 mg/hr • 3% saline @ 15 mL/hr • Insulin drip: 3 units/hr • KCl: 20mEq as needed

10. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

11. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

12. Pathophysiology • Causes of neurological damage due to stroke or brain injuries • Mitochondrial damage • Production of free radicals • Reperfusion causing further damage

13. Why hypothermia may work… • Hypothermia counteracts multiple steps of cellular injury following acute stroke • Reduces oxygen consumption • Inhibit free radical formation and inflammatory responses • Limit edema • Lower the amount of intracellular calcium • Exact mode is still being researched

14. Benefits from metabolic effects • Neuroprotective effects by reduction or delay in metabolic consumption during the stress of a CNS injury • Reduces CMRO2 by 5% per degree Celsius • 5.9% reduction in energy • Slows lactic acid production to prevent acidosis • Lowers metabolic and energy demands • Promotes tissue preservation

15. Methods for Cooling: Surface • Cold air, water and/or ice through a thermoconductive blanket • Cooling jackets • Ice packing • Advantages • Noninvasive • Inexpensive • Easy to implement • Disadvantages • Fluctuations in body temperature • Prolonged time to achieve the temperature goal

17. Methods for Cooling: Intravascular • Infusion of ice-cold fluids through intravascular catheters (with metal or circulating cold water–filled balloon conductors) • Advantages • Shorter time to goal temperature • More precise hypothermic control • Less shivering • Disadvantages • More invasive • Higher cost

19. Potential Complications • Shivering • Pneumonia • Decreased cardiac output • Hyperglycemia • Thrombocytopenia • Hypokalemia • Loss of gut function • Fever

20. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

21. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

22. Energy expenditure in ischemic stroke patients treated with moderate hypothermia • 10 patients treated with moderate hypothermia (33∘C) following an acute ischemic stroke • Indirect calorimetry was performed over the first 6 days after admission • Mean daily TEE decreased significantly: • 1,549 kcals before initiation of hypothermia • 1,099 kcals the first day • 1,129 kcals the second day • 1,157 kcals the third day • Returned to baseline (and 16% above) after hypothermia was terminated

23. Modification of the Harris-Benedict Equation to Predict the Energy Requirements of Critically Ill Patients during Mild Therapeutic Hypothermia • 5 patients suffering from acute cerebral injuries who underwent mild hypothermia • Indirect calorimetry measurements: • Every 3-4 hours during cooling/re-warming • Every 12 hours during the steady hypothermic state • Basal metabolic rate decreased by 30.3% • Every drop in temperature by one degree led to a 5.9% reduction in energy • Measured TEE was 16.7% lower than calculated TEE

25. Metabolic Downregulation: A Key to Successful Neuroprotection? • Hypothermia slows but does not completely prevent the eventual depletion of ATP • Several studies suggest that metabolism is not significantly remarkable in neuroprotection • Example: rodents subjected to 20 minutes of forebrain ischemia • Brain levels of various metabolites were no different from rats who were in a normothermic state • Thus, the influence of hypothermia on cerebral metabolism probably does not fully explain its protective effect

26. My patient vs. Current Research

27. Equation vs. Calorimeter • Hypothermic State (32.8◦C) • 58% above the PSU equation calculation • Day 1 Re-warming (35.4◦C) • 51% above the PSU equation calculation • Day 2 Rewarming (37.1◦C) • 47% above the PSU equation calculation

30. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

31. Overview • Patient information • Therapeutic Hypothermia • Therapeutic hypothermia impacts on nutrition • My patient vs. current research • Nutritional assessment based on findings

32. NCP: Assessment • Calories • Prior to hypothermia protocol: • 2,475 kcals/day (PSU equation x 1.1) • During hypothermia protocol and medical paralysis: • 1,375 kcals/day (PSU equation) • After completion of hypothermia protocol: • 2,440 kcals/day (indirect calorimetry measurement) • Protein: 130 g/day (1.75 g/kg of adjusted body weight)

33. Alterations during admission • Prior to hypothermia protocol • Nutren 1.5 @ 80 mL/hr (x 21 hours) • Beneprotein: 3 scoops/L of feeding • Nutrisource Fiber: 2 scoops in 50 mL of water 4x/day • During hypothermia protocol and medical paralysis • Replete @ 70 mL/hr (x 19.5 hours) • Beneprotein: 5 scoops/L of feeding • Nutrisource Fiber: 3 scoops in 75 mL of water 4x/day • After completion of hypothermia protocol • Nutren 1.5 @ 85 mL/hr (x 19.5 hours) • Beneprotein: 3 scoops/L of feeding • Nutrisource Fiber: 3 scoops in 75 mL of water 4x/day

34. NCP: Diagnosis • Increased nutrient needs (energy) (NI- 5.1) related to therapeutic hypothermia protocol as evidenced by resting metabolic rate calorimetry measurement of 1,950 calories while in a hypothermic state.

35. NCP: Intervention • Food and or/nutrient delivery (ND) • Enteral and Parenteral Nutrition (ND-2) – Enteral Nutrition (ND-2.1) – Composition: • Provided nutrition through the GI tract via keofeed tube based on patient’s calculated protein and measured energy needs.

36. NCP: Monitoring and Evaluation Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution Criteria: Patient will receive Nutren 1.5 @ 80 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 2 scoops in 50 mL of water 4x/day in order to meet her calculated protein and energy requirements.

37. Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution Criteria: Patient will receive Replete @ 70 mL/hr, Beneprotein 5 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water 4x/day in order to meet her energy requirements during the hypothermia protocol. Indicator: Enteral nutrition intake (FH-1.3.1) – Formula/solution Criteria: Patient will receive Nutren 1.5 @ 85 mL/hr, Beneprotein 3 scoops/L of feeding, and Nutrisource Fiber 3 scoops in 75 mL of water four times per day in order to meet her energy requirements after the hypothermia protocol is complete.

38. Conclusion • Limited research • Measurement of my patient prior to hypothermia protocol may have given a different result • Case-to-case basis • Establish measurement in protocol • Therapeutic hypothermia may have benefits, but not necessarily nutritionally

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