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THERAPEUTIC HYPOTHERMIA

THERAPEUTIC HYPOTHERMIA. Heike Geduld August 2007. What is it?. First described in 1950s but no formal testing Revival of interest following animal studies Moderate hypothermia - core temperature 32-34ºC. When is it used?. Out-of hospital cardiac arrest In-hospital cardiac arrest

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THERAPEUTIC HYPOTHERMIA

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  1. THERAPEUTICHYPOTHERMIA Heike Geduld August 2007

  2. What is it? • First described in 1950s but no formal testing • Revival of interest following animal studies • Moderate hypothermia - core temperature 32-34ºC

  3. When is it used? • Out-of hospital cardiac arrest • In-hospital cardiac arrest • Head Injury/ Ischaemic stroke • Perinatal asphyxia • Cardiac surgery • Neurosurgery • Vascular surgery

  4. What is the evidence? From animal models - moderate hypothermia cerebral metabolic O2 rate suppress chemical reactions associated with reperfusion injury

  5. Out-of Hospital VF arrest with ROSC • 2 randomised controlled trials European - within 4hrs, for 24hrs 55% vs 39% favourable neurological outcome Mortality 41% vs 55% (included 10pts with IHA)

  6. Australian study pseudorandomised, maintain temp for 12hrs 51%vs 26% favourable neurological outcome 51 vs 68% mortality

  7. Problems • Highly specific population - excluded persistently hypotensive pts (SBP<90) Only pts whose cause of arrest was cardiac- VF arrest primarily Mostly out-of-hospital

  8. Complications • Low cardiac index • arrythmias • Pneumonia • Sepsis • Bleeding • Local cold injury • Rebound hyperthermia

  9. In Head Injury? • Cochrane review 2004 - no evidence for benefit

  10. Therapeutic hypothermia following perinatal asphyxia. Arch.Dis Child Fetal Neonatal Ed. Mar 2006;91.F127-31 Edwards AD, Azzopardi DV. Division of Clinical Sciences, Faculty of Medicine, Imperial College London, UK. David.Edwards@imperial.ac.uk Well constructed and carefully analysed trials of hypothermic neural rescue therapy for infants with neonatal encephalopathy have recently been reported. The data suggest that either selective head cooling or total body cooling reduces the combined chance of death or disability after birth asphyxia. However, as there are still unanswered questions about these treatments, many may still feel that further data are needed before health care policy can be changed to make cooling the standard of care for all babies with suspected birth asphyxia.

  11. How do we induce hypothermia? • DIFFICULT! • Use of icepacks, cooling helmets or vests. Cooling mattresses • Labour intensive • Often limits access to patients

  12. Whole body Cooling systems

  13. Intravenous Cooling • 30ml/kg crystalloid at 4ºC over 30 min - sufficient to reduce core temperature With only very small risk of pulmonary oedema

  14. Stop the shivering! • Shivering leads to warming • Increases oxygen consumption • Use sedation and muscle relaxation to stop shivering

  15. Who do we not use it on? • Children - not enough evidence for recommendation • Pregnant patients • Severe cardiogenic shock • Primary coagulopathies

  16. Current ILCOR recommendations • Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours when the initial rhythm was VF. (Class 11a) • Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest. (Class 11b)

  17. Join us for the Therapeutic Temperature Management Congress.Registration includes:attendance to 3 days of meetings with the worlds experts in temperature managementlearning materialslodging at a world class resortmeals during the conference (breakfast and lunch)an evening welcome receptiona thank you party night for all attendeesall hotel transfers to and from the airportPlan now! Limited registration is available.

  18. References 1. Therapeutic Hypothermia After Cardiac Arrest An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation Circulation. 2003;108:118. • Therapeutic hypothermia for head injury. Alderson P, Gadkary C, Signorini DF. The Cochrane Database of Systematic Reviews 2007 Issue 3 • Therapeutic hypothermia following perinatal asphyxia.Edwards AD, Azzopardi DV. Arch Dis Child Fetal Neonatal Ed. 2006 Mar;91(2):F127-31. 4. McIntyre LA, Fergusson DA, Hert PC, et al. Prolonged therapeutic hypothermia after traumatic brain injury in adults: a systematic review. JAMA. 2003;289:2992-2999.

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