SARASOTA MEMORIAL HOSPITAL. INITIATION AND MAINTAINANCE OF Normothermia/Temperature Managment

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1 SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE Temperature Management ThermoGard XP or Arctic Sun (crc26) DATE: REVIEWED: PAGES: 5/15 5/18 1 of 8 PS1094 ISSUED FOR: Nursing RESPONSIBILITY: Critical Care PURPOSE: KNOWLEDGE BASE: To establish guidelines for the therapeutic use of normothermia to treat patients with neurological disorders such as acute ischemic stroke traumatic brain injury (TBI), Subarachnoid hemorrhage (SAH) and trauma patients Multiple studies have concluded that normothermia improves neurological recovery and survival in patients resuscitated from cardiac arrest of presumed cardiac origin, and data suggests that patients with acute ischemic stroke, SAH, TBI and trauma may also benefit from this procedure. PROCEDURE: INITIATION AND MAINTAINANCE OF Normothermia/Temperature Managment Note: There are two separate order sets for Temperature Management One titled Neuro Temperature Management and One titled ICU Neuro temperature Management there are also specific orders for temperature management and maintaining normothermia in the SAH Order Set 1) Patient must be admitted to Critical Care. 2) Protocol may be initiated in Critical Care, ECC, Operating Room or Cardiac Cath Lab. 3) Initiate the order set per physician orders. 4). Shivering protocol : Refer to the order set. NORMOTHERMIA USING ENDOVASCULAR DEVICE 7). The ICY catheter or Quattro catheter can ONLY be placed femorally. 9). Prepare Zoll ThermoGard XP system for use: a. Open the top cover of the ThermoGard XP. Open the transparent top cover of the roller

2 (crc26) PAGE: 2 of 8 pump and the coolant well cap. b. Check coolant level. The liquid level should be between the two indicator lines on the wall of the coolant well. c. Open the Zoll Start up Kit and insert the heat exchanger coil into the coolant well. d. Temporarily slide the air trap into its holder. e. Locate the pump tubing and route it to the right side of the roller pump. Do not stretch or pull on the tubing. The tubing lengths and flanged connector allow the tubing to fit into the pump in only one direction. f. Lift the handle on the pump rollers. g. Place the flanged connector of the pump tubing into the slot on the right side of the pump head. h. Load the pump tubing around the rollers and into the channel of the pump head and turn the handle counterclockwise as you feed the tubing into the channel. One the tubing is installed, press the handle down onto the rollers until it clicks. i. Close the top cover on the pump and the coolant well. j. Using aseptic technique, connect the priming line to the sterile saline container with the spike connector. Insert the saline container in the insulating jacket and hang it on the hook provided. k. Lift out the air trap from its holder and turn it upside down (with the tubing connections pointing downward). Press and hold the prime switch until the air trap and tubing are completely full of saline (This will take approximately 2 minutes). Tap the air trap to dislodge any remaining air bubbles. Release the priming switch when there are no bubbles remaining in the saline container. l. Turn the air trap right side up and insert it in the holder. m. Place the tubing to the catheter in the two notches at the front of the console. Place the priming line and the saline return line in the channels leading to the rear of the console. Close the top cover of the ThermoGard XP. n. After the system runs a self test, the

3 (crc26) PAGE: 3 of 8 standby screen will appear. o. Select the Select target temperature at 37 degrees C. 4) Insert rectal probe into the patient and connect to the machine. 5) Connect the heat exchange balloon ports of the catheter to the tubing using aseptic technique. 6) Document beginning patient temperature in the Vital sign flowsheet of the EMR. 7) Initiate treatment by pressing the Standby/Run button once. The standby banner will disappear, the pump will start, and treatment will begin. 8) Once treatment has begun, confirm that saline is flowing through the tubing and catheter circuit by observing the rotation of the inline flow indicator. If it does not rotate freely, check the entire tubing circuit for kinks or other restrictions to flow. 9) Document rectal temperature every 30 minutes until the desired core temperature has been met. If the patients temperature has NOT DECREASED by at least 2 degrees Celsius within the FIRST hour of cooling, place ice packs to axilla, groin and top of head, or consider placing a cooling blanket on top of the patient. If the patient has not warmed consider applying a Bair Hugger. 10) Document the patient temperature and hypothermia unit settings every hour for the duration of treatment, in the Vital Signs flowsheet of the EMR. 11) Maintain a core temperature of 37 degrees PATIENT CARE 1. Apply warm blankets, wrapping the patients head, hands and feet, as well as placing a warm blanket over the patient, this will assist in the prevention of shivering. Also consider BAIR HUGGER IF UNABLE TO WARM PATIENT. 2. AVOID cold material (i.e. plastic tubing) from touching the patients skin, by placing a bath blanket on the patients thigh, under the Zoll tubing.. 3). machine temperature to 37 degrees C for normothermia for four total days (with the ICY or Quattro

4 (crc26) PAGE: 4 of 8 catheter) 3) Document vital signs every hour and prn with any hemodynamic or cardiac rhythm instability. In the Vital sign flowsheet of the EMR. 4). Notify neurologist or intensivist of any changes in patient condition. 5). Upon discontinuation of therapy, clean the machine and take to the Equipment Storage Room on 5CCT or 4CCT. 6) Catheter should be removed or replaced within 4 days for the ICY/Quattro catheter and must be discontinued prior to the patient transferring from the critical care unit. INITIATION AND MAINTAINANCE OF INDUCED THERAPEUTIC HYPOTHERMIA NORMOTHERMIA USING EXTERNAL DEVICE ARCTIC SUN Prepare Arctic Sun System for use: 1. Turn Power on (a brief selftest appears) 2. Check water level. If water level is low fill with either distilled water or sterile water (follow directions on screen) 3. Insert rectal probe into patient and place into P1 port on machine 4. Open the Arctic Gel pads (verify appropriate size pads are used- patients weight and shape will determine pad size) Arctic gel pads have a universal pad that must be placed on patients who weigh over 220 pounds or 100 kgs. 5. Assess the patients skin for any areas of burns, hives, rashes or ulcerations (gel pad NOT to be placed on those

5 (crc26) PAGE: 5 of 8 areas) 6. Gel pads are to be placed on dry skin and replaced every five days 7. Remove a portion of the barrier (white paper) from gel pad before applying to skin and then remove all barrier paper as continuing to apply. 8. Arctic Sun gel pads will be placed on upper torso extending to the spine allow at least 2 inches to separate the pads on either side of the spine. Avoid breast tissue on females. ( defibrillator pads can be placed under gel pads) 9. Arctic Sun gel pads will also be placed on both upper thighs. 10. Once arctic sun gel pads are in place connect the appropriate blue and white colored pad lines to the same colored fluid delivery lines on the Arctic Sun machine. (Connectors will click into place) 11. Press normothermia button on Arctic Sun machine (target temperature will be preset 37 degree C) 12. Water flow must be between 2-4 liters per minute or higher. 12) Document beginning patient temperature in the Vital sign flowsheet of the EMR. 13) Once treatment has begun, confirm that water flowing through the tubing, check the entire tubing circuit for kinks or other restrictions to flow. 14) Document rectal temperature every 30 minutes until the desired core temperature has been met. If the patients temperature has NOT DECREASED or INCREASED by at least 2 degrees Celsius within the FIRST hour of normothermia-do NOT place ice packs to

6 (crc26) PAGE: 6 of 8 axilla, groin and top of head, or consider placing a cooling blanket on top of the patient call the physician or the Consider patient shivering or seizing. 15) Document the patient temperature and normothermia unit water temperature settings every hour for the duration of treatment, in the Vital Signs flowsheet of the EMR. 16) Maintain a core temperature of 37degrees for five total days UNLESS PHYSICIAN ORDERS CHANGE. Arctic Sun gel pads must be changed after five days. PATIENT CARE 1. Apply warm blankets, wrapping the patients head, hands and feet, as well as placing a warm blanket over the patient, this will assist in the prevention of shivering. 2. Inspect the skin under every 4 6 hours under the gel pads. Avoid the use of lotions, oils or powders 3. DO NOT SHAVE SKIN 4. DO NOT PLACE ELECTROSURGICAL GROUNDING (BOVIE PADS) UNDER GEL PADS 5. SCD S CAN BE APPLIED 6. Arctic gel pads safe for CT and MRI (pads will remain cool/ warm for 20 minutes) 7. Arctic gel pads have a universal pad that must be placed on patients who weigh over 220 pounds or 100 kgs. 8. If a gel pad becomes soiled replace with the universal pad (DO NOT OPEN NEW GEL PAD SET) 9. You must empty gel pads prior to disconnecting! 10. If for any reason, the Arctic Sun gel pads cannot be used place the patient on the Maxi- Therm Hypothermia Unit. Use two warming blankets, placing one under the patient and one over the patient. Also consider BAIR HUGGER IF UNABLE TO WARM PATIENT. 11. Document vital signs every hour and prn with any hemodynamic or cardiac rhythm instability. In the Vital sign flowsheet of the EMR. 4). Notify neurologist or intensivist of any changes in patient condition. 12. Upon discontinuation of therapy, clean the machine and take to the Equipment Storage Room on 5CCT or 4CCT.

7 (crc26) PAGE: 7 of 8 TROUBLE SHOOTING THE ARCTIC SUN 1. Patient temperature falls below target: cause administering a paralytic or new vasoactive drug machine will adjust 2. Water temperature falls more than 10 degrees C. check patient for shivering/seizures and medicate per protocol. 3. Call for any trouble shooting issues. EXCEPTIONS: See inclusion criteria REFERENCES: Bro-Jeppesen J, Hassager C, Wanscher M, Søholm H, Thomsen JH, Lippert FK, Møller JE, Køber L, Kjaergaard J.(2013). Posthypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest. Resuscitation (12): doi: /j.resuscitation Epub 2013 Aug 2. PubMed PMID: Winters SA, Wolf KH, Kettinger SA, Seif EK, Jones JS, Bacon-Baguley T. (2013). Assessment of risk factors for post-rewarming "rebound hyperthermia" in cardiac arrest patients undergoing therapeutic hypothermia. Resuscitation (9): doi: /j.resuscitation Epub 2013 Apr 6. PubMed PMID: Diller KR, Zhu L. Hypothermia therapy for brain injury. Annu Rev Biomed Eng. 2009;11: doi: /annurev-bioeng Review. PubMed PMID: Medivance. (2014). Arctic Sun 5000 Operating Manual

8 (crc26) PAGE: 8 of 8 AUTHORS: Kelly Comingore, BSN, RN, CCRN, NPD, Critical Care & Hemodialysis Kimberly Gray, RN, NPD, Critical Care

SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

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