Post-Resuscitation Care: Optimizing & Improving Outcomes after Cardiac Arrest. Objectives: U.S. stats
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1 Post-Resuscitation Care: Optimizing & Improving Outcomes after Cardiac Arrest Nicole L. Kupchik RN, MN, CCNS CCRN-CMC Clinical Nurse Specialist Harborview Medical Center Seattle, WA Objectives: At the end of the learning activity the attendee will be able to: Discuss evidence-based care of the resuscitated patient. Discuss hemodynamic optimization after cardiac arrest. Discuss the benefits of implementing therapeutic hypothermia after cardiac arrest. U.S. stats About 164,600 out-of-hospital cardiac arrests occur annually in the US aha.org (2007) The incidence of cardiac arrest with an initial rhythm of ventricular fibrillation is decreasing over time (Cobb LA, Fahrenbruch CE, Olsufka M, Copass MK. Changing incidence of out-of-hospital ventricular fibrillation, JAMA. 2002;288: ) The rate of survival to discharge after in-hospital cardiac arrest is 18% among adults However, adults with an initial rhythm of ventricular fibrillation or ventricular tachycardia have a similar good prognosis (32% survival to discharge) (Nadkarni V, et al, for the National Registry of Cardiopulmonary Resuscitation Investigators. First documented rhythm and clinical outcomes from in-hospital cardiac arrest among children and adults. JAMA. 2006;295:50-57) U.S. survival to discharge is 6.4% (Nichol et al. 1999, Annals of Emerg. Med. 34(4):517-25) Seattle survival to discharge is ~20% (Cobb et al. 2002, JAMA 288(23): )
2 Sept. 23, 2008 Cardiac Arrest Location, Location, Location!!! Regional Differences: 10 cities JAMA (2008); Nichol et al. JAMA, 2008 Nichol et al. Designated cardiac arrest centers Arizona 24/7 Cardiac Catheterization Therapeutic Hypothermia Center are identified by the AZ DOHS NYC January 2009 Therapeutic Hypothermia Resuscitation 2008; Spaite et al, 79(1); OPALS Study: Outcomes better at larger teaching hospitals vs. small & rural hospitals with higher volumes Annals of Emerg Med 2008; Spaite et al.
3 Trends in Resuscitation Pre-hospital phase Early defibrillation Quality CPR Post arrest: Supportive care
4 Therapeutic Hypothermia after Cardiac Arrest n Randomization Temp. Rhythm Results Bernard et al. NEJM (2002); 346(8): Hypothermia 34 Control 33 x 12 hrs V-fib 21/43 (49%) w/ good neuro outcome (Hypothermia) 9/34 (26%) w/ good neuro outcome (Control) (p=0.046) HACA NEJM (2002); 346(8): Hypothermia 138 Control x 24 hrs V-fib/ V-tach 75/136 (55%) w/ good neuro outcome (Hypothermia) 54/137 (39%) w/ good neuro outcome (Control) (p=0.009) RR 1.4 (95% CI ) HACA trial Median initiation of cooling = 105 min. Median time to goal temp = 8 hours
5 ILCOR/ACLS Advisory Statement October 2002, the Advanced Life Support (ALS) Task Force recommended: Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to C for 12 to 24 hours when the initial rhythm was ventricular fibrillation IIa Recommendation Such cooling may also be beneficial for other rhythms or in-hospital arrest IIb Recommendation Circulation 2003;108; Can we safely cool cardiogenic shock/pci? Previous trials excluded patients with shock symptoms, few with PCI Outcomes of 50 patients 23/50 received IABP, 36/50 PCI 41 (82%) survived until 6 mos. 34 (68%) CPC 1 or 2 7 (14%) CPC 3 Hovdenes, J., et al (2007). Therapeutic hypothermia after out-of-hospital cardiac arrest: experiences with patients treated with percutaneous coronary intervention and cardiogenic shock. Acta Anaesthesiol Scand; 51:
6 491 patients from January 1, 2001 December 31, 2004 Reperfusion Injury Depleted stores of O 2 & glucose Intracellular calcium influx Formation of O 2 free radicals Release of glutamate Intracellular acidosis Disruption in blood brain barrier Mitochondrial injury Apoptosis Neuro-Protective Qualities: Cerebral Metabolic Rate Intracranial pressure Inflammation & cytokine release Cerebral edema
7 Physiologic Effects of Hypothermia Systemic effects of hypothermia: Heart rate Cardiac output (by up to 25%) BP & SVR (d/t vasoconstriction) Urine output Lactate Prolonged clotting times Intestinal motility Arrhythmias/ECG changes Negative chronotropic effects of pacemaker cells Prolonged PR, QT intervals J wave More susceptible to atrial fibrillation (<32 C) Ventricular arrhythmias at lower temps (Below C)
8 Electrolyte Imbalance Decreased: Due to intracellular shifts -Potassium -Magnesium (has neuro-protective qualities) -Phosphate -Calcium Assess electrolytes upon initiation, goal, then at regular intervals (q 4-6 hrs) Hyperglycemia: insulin secretion Glucose Control 234 subjects post cardiac arrest Assessed glucose levels 12 hours after ROSC with 6 month survival Conclusion: Tight control may not be needed -Losert et. al. (2007); Resuscitation 90 subjects post vfib arrest/therapeutic hypothermia Strict glycemic control group, moderate group Conclusion: No survival benefit from strict glycemic control -Okanen et. al. (2007); Intensive Care Medicine ABGs Shift to the left Decreased O 2 consumption CO 2 production slows
9 Oxygen Saturation Monitoring Digit sensor often unreliable d/t peripheral vasoconstriction Study compared forehead sensors with digit sensors Shivering: Increases O 2 consumption by % Neuromuscular blockade Ensure adequate sedation TOF monitoring- unreliable <35º C (slowing of neuromuscular junction) Other strategies: Propofol/Sedatives Opiates Meperidine Columbia Shiver Scale Badjatia et al, Stroke; Pending publication, 2009
10 Monitoring Temperature Pulmonary Artery (PA) catheter Bladder Esophageal Rectal Fallis, W.M. (2002). Monitoring urinary bladder temperature in the Intensive Care Unit: State of the Science. American Journal of Critical Care; 11(1): Methods of Cooling Surface Ice packs External water blankets Forced cool air blankets Hydrogel Endovascular Catheters Challenges with cooling: Obese patients (Adipose insulates 3x s as well as muscle) Young patients (react to changes in body temperature) Easy cooling: Older patients -Lower BMI -Lower rate of metabolism -Less effective vascular response
11 Re-warming Important to re-warm slowly (8-24 hours) If re-warm too quickly, can possibly negate benefits of hypothermia Rebound hyperthermia
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