Therapeutic Hypothermia ANZCA 2013
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1 Therapeutic Hypothermia ANZCA 2013 Stephen Bernard MD
2 Therapeutic Hypothermia-Indications Anoxic brain injury (cardiac arrest) Severe traumatic brain injury Spinal cord injury
3
4 Why not Therapeutic Hypothermia? Possible adverse effects: Bleeding Pulmonary infection Wound infection Cardiac arrhythmias Electrolyte changes
5 Out of hospital cardiac arrest
6 Hypothermia after Cardiac Arrest:
7 Hypothermia after Cardiac Arrest: % good outcome Australia p = % 26% Europe *** 55% 39% 25 0 control hypo T control hypo T (***risk ratio 1.40, CI )
8 THE RICH Trial Hypothesis: Immediate cooling by paramedics using 2000ml ice cold IV Hartmanns immediately after resuscitation from cardiac arrest improves outcome compared with cooling after hospital arrival
9 Trial Protocol: Inclusions: Post cardiac arrest > 10 minutes downtime Adults > 17 years ROSC with BP > 90mHg systolic (+/- adrenaline infusion) VF and non-vf enrolled separately
10 Trial Protocol: Exclusions: Temperature < 34.5 C Obvious pregnancy Not independent in ADL Arrest in presence of paramedics
11 Trial Protocol: Paramedic Cooling Immediately post return of spontaneous circulation Midazolam 1-5mg and pancuronium 12mg IV Infuse stat 2000mL ice-cold Hartmanns via peripheral IV line Record tympanic temperature / vital signs before and after
12 Trial Protocol: Hospital Cooling Cooling after ED arrival 3000mL ice-cold Hartmann s (total 40mL/kg) stat Ice packs (10) or Arctic Sun (2) 33 C for 24 hours Rewarm over 12 hours Usual care after 36 hours
13 6,436=Adults ( 15 y) with cardiac arrest during trial period 4,763=Cardiac arrest of presumed cardiac cause 2,268=Resuscitation attempted by paramedics 842=Initial cardiac rhythm ventricular fibrillation 398=Return of spontaneous circulation and transported to hospital 444=died at scene (53%) 118 assigned paramedic cooling 116 assigned to hospital cooling
14 The RICH VF RCT: Demographics EMS cooling ED cooling Age (years) Male/ female % 83% 86% Bystander CPR % 69% 67% Downtime (min) Defibrillations 4 4 Adrenaline (mg) 2 3 Fluid during CPR
15 hours hospital hospital 95%CI paramedic paramedic 95%CI
16 Trial data: 234 post VF arrest Outcome: 60 52% vs 47% % % vs 51% p=ns EMS ER Home Rehab NH awake NHcoma Dead
17 Trial data: 163 post non-vf arrest Outcome: % % vs 9% p=ns EMS ER Home Rehab NH awake NHcoma Dead
18 Therapeutic hypothermia during CPR? The RINSE trial RCT NHMRC funded Compares bolus 30mL/kg ice-cold IV fluid during CPR with standard care 2520 patients from 3 states Melbourne, Perth, Adelaide 751 recruited to date
19 Therapeutic hypothermia during CPR? The CHEER trial Pilot observational trial Post-VF arrest <65 years No ROSC at 30 minutes CPR to ED Hypothermia ECMO Emergency Reperfusion
20 Therapeutic hypothermia during CPR? The CHEER trial Only 4 patients in 1.5 years from 3 ambulance units Data from VACAR for Melbourne/ 12months/ age < 65 and VF arrest 222 patients 149 ROSC 68 no ROSC
21 Therapeutic hypothermia during CPR? The CHEER trial Only 4 patients in 1.5 years from 3 ambulance units Data from VACAR for Melbourne/ 12months/ age < 65 and VF arrest 222 patients 149 ROSC 68 no ROSC
22
23 In hospital cardiac arrest: Therapeutic Hypothermia?
24 23 year old female undergoing plastic surgery at suburban hospital High ETCO2 during surgery (LMA) Spontaneously breathing on arrival at PACU Asystolic arrest CPR (OT and paramedics) ROSC at 17 minutes Immediate transfer to tertiary centre within 15 minutes of ROSC
25 On examination in ED: ETT and IPPV Comatose PERL GCS 3 Hemodynamically stable Role of therapeutic hypothermia?
26 In hospital arrest: Therapeutic hypothermia 538 hospitals participating in the Get With the Guidelines in-hospital arrest database ,498 patients who had return of spontaneous circulation after in-hospital cardiac arrest., Therapeutic hypothermia was initiated in 1,367 patients (2.0%) Mikkelsen ME,et al. Use of Therapeutic Hypothermia After In-Hospital Cardiac Arrest. Crit Care Med 2013 Mar 20. [Epub ahead of print]
27 In hospital arrest: Therapeutic hypothermia The target temperature (32-34 C) was not achieved in 44.3% of therapeutic hypothermia patients within 24 hours and 17.6% were overcooled Increased likelihood of therapeutic hypothermia being initiated. younger age (p < 0.001) occurrence in a non-icu location (p < 0.001) weekday (p = 0.005) teaching hospital (p = 0.001)
28 In hospital arrest: Therapeutic hypothermia Back to our patient Some anoxic brain injury likely Animal data very supportive OHCA data not very relevant Immediate high quality CPR Hypercapnea + hypoxia injury
29 In hospital arrest: Therapeutic hypothermia Back to our patient Treatment 40mL/ kg ice saline IV bolus Cooling jacket 32C for 24 hours Recovered to normal
30 Cardiac Arrest: Therapeutic hypothermia Summary Hypothermia during CPR should be considered during prolonged resuscitation using 40mL/kg ice-saline bolus Hypothermia post CPR should be given if anoxic brain injury is likely You need the right equipment
31 TBI: Therapeutic hypothermia
32
33 TBI: Therapeutic hypothermia Current trials POLAR EUROTHERM 3235
34 TBI: Therapeutic hypothermia POLAR In patients with severe TBI does early and sustained mild hypothermia compared with standard care (normothermia) increase favourable neurological outcomes at 6 months post injury?
35 TBI: Therapeutic hypothermia POLAR NHMRC and TAC funded ANZICS Research Centre Requires 512 patients in 5 centres Paramedic cooling (2L cold fluid stat) 72 hours of hospital cooling (surface cooling) POM=6 month GOSE
36 TBI: Therapeutic hypothermia Inclusion criteria Severe blunt traumatic brain injury (GCS) 8) Estimated age The patient is intubated or intubation is imminent
37 TBI: Therapeutic hypothermia Exclusion criteria Coma caused by ETOH or drugs Time since injury >3 hrs Estimated transport time >2.5hrs Can be intubated without drugs Systolic BP <90mmHg Heart rate > 120bpm GCS=3 + un-reactive pupils Cardiac arrest at scene or in transit Penetrating neck/torso injury Known or obvious pregnancy Current anti-coagulant therapy Receiving hospital not a study site Known to be carer-dependent due to previous neurological condition
38 TBI: Therapeutic hypothermia
39 TBI: Therapeutic hypothermia EUROTHERM 3235 In ICU patients with severe TBI and elevated ICP, does mild hypothermia compared to standard care (normothermia) increase favourable neurological outcomes at 6 months post injury?
40 TBI: Therapeutic hypothermia EUROTHERM patients Funded by ESICM UK, Estonia, Hungary, Greece, Northern Ireland ICP>20 for>5 minutes despite initial measures within 72 hours of injury Hypothermia (32C-35C) for 72 hours or standard care (thiopentone) POM=GOSE at 6 months
41 SURGICAL DRAINAGE of CLOT VENT CSF SEDATION (M/M/P) +/-NMBA OSMOTHERAPY 7.5%saline (Na ) THIOPENTONE HYPOTHERMIA
42 TBI: Therapeutic hypothermia Summary Early hypothermia should only be done in the context of a clinical trial Hypothermia for the treatment of raised ICP is a reasonable alternative to thiopentone
43 Therapeutic hypothermia after spinal cord injury?
44 Background: Mechanism of injury Direct trauma Ischaemia/ reperfusion Animal studies suggest TH benefit One anecdotal report One pilot clinical trial
45 Animal data: METHOD. A spinal cord contusion (12.5 mm at T-10) was produced in adult rats: Group 1 rats received hypothermic treatment (epidural temperature 32-33C) 30 minutes post-injury for 4 hours Group 2 rats received normothermic treatment (epidural temperature 37C) 30 minutes post-injury for 4 hours Yu CG, J Neurosurg 2000; 93:85-93
46 Animal data: RESULTS. Mean BaBeBr scores: Hypothermia animals are the filled circles and normothermia (37 C) are represented by triangles Basso DM, Beattie MS, Bresnahan JC. A sensitive and reliable locomotor rating scale for open field testing in rats. J Neurotrauma 1995; 12:1-21
47 Therapeutic hypothermia plus surgical decompression after spinal cord injury?
48
49 Rats were subjected to a moderate mid-thoracic SCI and spacers were inserted to compress the spinal cord by 45%. Decompression, by removal of the spacer, was performed immediately and at 2 or 8 h post-injury. Hypothermia (33 C) was commenced in half the animals at 30 mins post-injury and maintained for 7.5 h, with the other half remaining normothermic (37.3 C) Batchelor PE, et al. Hypothermia prior to decompression: buying time for treatment of acute spinal cord injury. Journal of Neurotrauma 2010; 27:
50
51 Hypothermia significantly improved the behavioral and histological outcome of animals undergoing 8 hours of compressive injury. The hypothermia-treated group regained weightsupported locomotion (BBB locomotor assessment score 9.5 ± 0.9) while the normothermic group remained severely paraplegic (BBB score 5.3 ± 0.6; p 0.001) Current NHMRC grant application: Immediate Cooling and Emergency Decompression (ICED)
52 USA TODAY: Buffalo Bills Football Player Receives New Spinal Treatment An experimental treatment was used on Buffalo Bills football player Kevin Everett to prevent paralysis from a spinal injury the key was the quick action taken to run an ice-cold saline solution through Everett s system so that put the player in a hypothermic state
53
54 Measures of successful outcome:
55 Measures of successful outcome: Appeared on Oprah
56 Measures of successful outcome: Appeared on Oprah Wrote a best seller
57 Therapeutic hypothermia: Techniques
58
59 Standard cooling jackets Slow (<1 C per hour) Inexpensive ($150) Convenient (nurse initiated)
60 Intravascular catheter Faster (2 C per hour) Expensive ($1500) Requires physician to insert
61 Cold fluid infusion Faster (2 C in 30 minutes) Inexpensive ($3.20) Transient Convenient Possible APO
62 Intranasal flurocarbon (Benechill ) Faster (3 C per hour) Expensive (>$2500) Unproven for total brain cooling Current RCT underway
63 Peritoneal lavage (Velomedrix ) Much faster (10 C per hour) Inexpensive ($500) Invasive Current RCT underway for STEMI Velomedix Platform Peritoneal Catheter Touchscreen Interface Solid state Cooling, Warming Core Temp Probe Lavage Fluid Line Refrigerator (Disposable fluid bags inside)
64 Cold body lavage Thermosuit system Faster (>3C per hour) Expensive (>$1000) Inconvenient
65 Others Head cooling (does not work) Ethanol/ vasopressin/ lignocaine (lab only) ECMO (expensive) CVVHF (time consuming) Frozen gel jackets (inconvenient) Cooled LMA (not tested)
66
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