CHILL OUT! Induced Hypothermia: Challenges & Successes in the

Transcription

1 CHILL OUT! Induced Hypothermia: Challenges & Successes in the ICU Colleen Bell RN, BS, CCRN, Donna Brault RN, BSN, CCRN, Cathy Patnode RN, BSN, CCRN Champlain Valley Physician Hospital November 2012

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3 Objectives Review benefits of and recommendations for therapeutic induced hypothermia Discuss management techniques of cooling and re-warming patients Identify the potential complications of hypothermia and associated treatment risks

4 The Evidence Early Research in 1950 s inconclusive Animal Research 2002 ILCOR ALS Task Force Recommendation after 2 randomized trials: The European Study and The Australian Study (Nolan,2003)

5 ILCOR Recommendations International Liaison Committee on Resuscitation Unconscious adult patients with ROSC after out- of-hospital cardiac arrest should be cooled to 32 to 34 degrees celsius for 12 to 24 hours when the initial rhythm was VF Such cooling may also be beneficial for other rhythms hth or in-hospital it cardiac arrest

6 Mechanisms of Action Hypothermia reduces cerebral metabolic rate for oxygen Reduced normal electrical activity Suppressed chemical reactions associated with reperfusion injury

7 Potential Adverse Effects: Arrhythmias Infection/Sepsis Coagulopathy Electrolyte abnormalities Skin Breakdown

8 Criteria Inclusion Within 6 hrs post cardiac arrest ROSC <60min Maintaining BP with or without pressors Patient Comatose Exclusion Head Trauma Surgery within 14 days Coma from other causes Systemic infection/sepsis Bleeding

9 Cooling Techniques es External cooling blankets

10 Cooling Techniques es Ice packs to axillae, groin, and neck IV infusion of cold solutions Irrigate body cavities (NG/foley)

11 Protocol Prior to the initiation of hypothermia Rule out other causes for comatose state Studies completed (CT scan, echo) Have baseline labs drawn Thorough h skin assessment Place Foley (temperature monitoring device), Central line, A-line No heating circuit on ventilator

12 Protocol Monitoring during therapy: Serial labs, electrolytes, coag studies, CBC, ABGs, Cardiac enzymes, cultures, toxicology MAP goal >90 and CVP>8 Continuous temperature monitoring

13 Protocol Cardiac monitoring: bradycardias, QT intervals Cool to C over 4-6 hrs Mineral oil to skin every 2 hr with diligent skin assessment Use NMB or sedation for shivering

14 Potocol Protocol Insulin drip (keep BS <140) Re-warm over 12 hours (0.5-1 degree C/hr or 1-2 degree F/hr) Watch for hypotension Watch for shivering Wean sedation and paralytics off when temp 98.6

15 2011 Data Summary 32% Cardiac arrest survival rate 3 met hypothermia criteria 3died 2012 (Jan-July) July) 44% Survival rate with routine use of therapeutic induced hypothermia 11 met criteria 7 died, 3 d/c d neuro intact, 1 w/ anoxic brain injury Data collected from retrospective chart review

16 Case Study 62 female e had witnessed v fib arrest and received multiple shocks prior to ROSC. EMS transported her to the local ER where she was intubated and stabilized for transport to CVPH Hypothermia started en route to CVPH, upon arrival brought to Cath Lab. Upon arrival to ICU, GCS 5 and unresponsive. Decorticate posturing noted.

17 Case Study (con t) Cooling process initiated with the Kool Kit, Temp maintained at 90.9F 9F to 94F Despite a versed drip uncontrollable shivering i was noted at hypothermic hour 23. Re-warming initiated

18 Case Study (con t) Pt. successfully extubated day 2 after cardiac arrest Alert but confused initially AICD placed At discharge, alert and oriented

19 Summary: lessons learned Cool early Maintain consistent therapeutic temperature for 24 hours Goal to cont data collection for cardiac arrest and Hypothermia outcomes (larger study size) Have a standardized di d measurement of neurologic status t upon discharge Consistent data collection

20 CONCLUSION Cerebral ischemia from cardiac arrest frequently leads to severe neurologic disabilities. Therapeutic Induced hypothermia is a promising method that increases the rate of favorable neurologic outcome.

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22 References ences Carey K, Fillmore L, (2007) Induced Hypothermia Protocol. Champlain Valley Physicians Hospital Plattsburgh NY Collins, T. J., & Samworth, P. J. (2008). Therapeutic hypothermia following cardiac arrest: a review of the evidence. Nursing in Critical Care 2008, 13(3), Field, J.M., Hazenski, M.F., Sayre, M.R., Chameides, L., Schexnayder, S.M., Samson, R.A., Vanden Hoek, T.L. (2010). Pat 1: Executive Summary: 2010 American Heart Associations Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(3) s640-s656. s656. Laird, P. (2009). Induced hypothermia for neuro protection following cardiac arrest: a review of the literature. Internet Journal of Advanced Nursing Practice, 10(2), 4. CINAHL Plus with Full Accessed October 26,2012 McLean, S. (2009). Induced moderate hypothermia after cardiac arrest. AACN Advanced Critical Care, 20 (4),

23 References ences Nolan J.P., Morley P.T., Vanden Hoek T.L., & Hickey,R.W. (2003). Therapeutic Hypothermia after cardiac arrest: An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee Resuscitation. Circulation.108 (1) Polderman, K. H. (2008). Hypothermia and neurological outcome cardiac arrest: state of the art. European Journal of Anaesthesiology, 25,,