Therapeutic Hypothermia. Jonas Cooper, MD MPH

Transcription

1 Therapeutic Hypothermia Jonas Cooper, MD MPH

2 Hypothermia in Cardiology Early cardiac surgery included cooling to 15 C and stopping all blood flow for one hour while surgery proceeded Belsey RH et al. Profound hypothermia in cardiac surgery. J Thorac Cardiovasc Surg 1968;56:

3 Hypothermia in EP

4 Implementing Hypothermia 1) Physician Champion Point Person to coordinate the efforts -The science aspect -The social aspect

5 Major Publications Holzer M, for the Hypothermia after Cardiac Arrest Study Group. NEJM 2002;346: Bernard S. et al. NEJM. 2002;346:

6 Hypothermia Results Survival: 14-16% absolute increase in survival Number needed to treat (NNT) 7 Cerebral Performance: NNT 6 to prevent one bad neurologic outcome Odds ratio (OR) 5.25 [ ] for good neurologic outcome

7 Patient Selection 2005 Guidelines (IIa): Out of hospital, VT/VF arrest, successful return of spontaneous circulation (ROSC) who remains unconscious

8 Patient Selection 2005 Guidelines (IIb): Consider for inpatient arrests Consider for other presenting rhythms

9 Implementing Hypothermia 2) Identify the Key Stakeholders -code / critical care committee -ICU director -any interested faculty Cardiology Pulmonary/Critical Care Neurology Emergency Medicine -nursing leadership

10 Implementing Hypothermia Misinformation may include -subgroup analysis -populating nursing homes with impaired survivors -prior studies show no benefit -nobody else is doing it -you need IRB approval

11 Implementing Hypothermia 3) Create a Protocol -cooling method -what setting (which ICU) -what patient population (start small?) -keep it simple

12 University of Pennsylvania Massachusetts General Hospital Cleveland Clinic University of Chicago Boston University University of Pittsburgh Baylor (St. Luke s Episcopal) School of Medicine University of California- San Francisco Inclusion Post VT and VF arrests, possibly after other rhythms Post-VT/VF arrest Any witnessed cardiac arrest of <60 minute duration Any cardiac arrest Any witnessed cardiac arrest Any cardiac arrest Any cardiac arrest VT,VF, PEA (all of known duration) Time window for cooling ASAP Within 6 hours of arrest Within 6 hours of arrest No limits, but ASAP is desired None mentioned Within 6 hours of resuscitatio n Within 6 hours of resuscitation No limits Cooling Initiation 2 Liters 4ºC saline IV over 30 minutes (Peripheral IV) Possibly 30 cc/kg 4 ºC saline over 30 minutes (Peripheral IV) 1.5 Liters 4 ºC normal saline None None Dampen skin, cooling fan, cool room 40 ml/kg iced IV NS via pressure bag and peripheral IV s (2 large bore) Immediate application of ice packs to head, torso, axillae, groin Cooling Method Gaymar III torso and thigh pads rapid cool setting until 34 ºC, then gradual cooling mode until 33 ºC External ice packs and cooling blanket system OR Arctic Sun cooling vest device (does not need paralytics) External ice on head (not ears), axillae, groins, dry towels on hands and feet Cooling blanket (K- Thermia system) or Gaymar III Alsius cooling femoral vein catheter with CoolGard system OR Ice packs and blankets Alsius Coolgard: Icy femoral catheter unless IVC filter, then cool-line for SVC/IJ line Cool no faster than 1 ºC/hour; Cooling blanket, ice cold fluid NG lavage, 2 liters cold IVF Ice packs if needed cooling machine Ice packs as above, and cooling blankets

13 Goal Temperatur e University of Pennsylvania Massachusett s General Hospital Cleveland Clinic University of Chicago Boston University University of Pittsburgh Baylor (St. Luke s Episcopal) School of Medicine University of California- San Francisco 33 ºC ºC 33 ºC ºC ºC 33 ºC 33 ºC 33 ºC Cooling Duration Rewarm 20 hours after target temperature reached Rewarm 24 hours after initiation of hypothermia Rewarm 24 hours after initiation of hypothermia Rewarm 18 hours after target temperatur e reached Rewarm 18 hours after target temperature reached Rewarm 24 hours after initiation of hypothermi a Rewarm 24 hours after reaching the goal temperature of 33 ºC Rewarm 24 hours after initiation of hypothermi a Sedation Fentanyl, Propofol Yes (not otherwise specified) Propofol, ±Fentanyl Fentanyl, Morphine, other Propofol, Versed, Fentanyl as needed to prevent shivering Midazolam Fentanyl and Versed Paralysis Cisatracuriu m Yes (not otherwise specified) unless using Arctic Sun (sedation only) Atracurium mg/kg IV bolus then ~5mcg/kg/mi n Yes (not otherwise specified) Vecuronium if unable to stop shivering with sedation.08-1 mg/kg iv bolus, then mg/kg iv q2h PRN Vecuronium as needed to prevent shivering.05-1 mg/kg Cisatracuriu m 0.15 mg/kg IVP then.5 mcg/kg/min infusion Vecuroniu m 0.1mg/kg bolus, 1mg/hour gtt Paralytic monitoring Not specified Not specified Train 1-2/4 Train 1/4 To control shivering To control shivering To control shivering Train 1/4

14 Where To Start

15 Inclusion Criteria Adult ( 18 y.o.) Return of Spontaneous Circulation Unresponsive to verbal command (GCS<8) Hemodynamically stable*

16 Exclusion Criteria Pregnancy Comatose pre-arrest Hypothermia <30 C on admission Terminally ill patients, DNR/DNI Genetic blood coagulation disorder Substantial delay until cooling possible?

17 Holzer M. NEJM 2010; 363: Cooling Choices

18 Cooling Protocol Sedation / Analgesia Paralysis (prevent shivering) Temperature Monitoring Glucose Control Ventilator Control Hemodynamic Control Seizure Monitoring?

19 Hypothermia Timeline BJC Hypothermia Protocol Timeline Core Body Temperature (ºC) * * * * * * Cooling: ~4 hours Time (2 hour increments) Maintenance: 18 hours Vital signs recorded every hour IV sedation throughout IV paralytics until temperature 36 ºC Labs drawn at asterisks Warming: ~5 hours

20 Pearls / Tricks Cool early, cool quickly, rewarm slowly Hypothermia induces diuresis, hypokalemia Rewarming causes vasodilation, hyperkalemia Paralytics prevent shivering Hypothermia DOES NOT interfere with acute coronary syndrome management

21 Acute Coronary Syndrome Improved survival (68% vs. 38%) Improved neurologic function (CPC % vs. 19%) No difference in IABP use, arterial pressure, need for cardioversion or antiarrhythmic drugs Knafelj R et al. Resuscitation 2007;74: Historical controls from

22 Pearls / Tricks Increases the QT interval Induced coagulopathy (Rx FFP, platelets) Hypothermia may increase risk of infection, sepsis Neurologic status can take several days to recover

23 Implementing Hypothermia 4) The Business Side -Hospital administration -Startup capital -Know your competition

24 AHA 2010 Guidelines Prediction: 1A Out of Hospital VT/VF 2A (Level B) all other rhythms and settings

25 Adopting New Interventions

26 Implementing Hypothermia 5) Final Planning -Nurse training/grand Rounds -Nursing call schedule? -Nursing manual -Standard order set -Physician champion available for inevitable problems

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28 Implementing Hypothermia 6) Publicize -Media relations -Bring in a speaker / Grand Rounds -Communicate with EMS -Education

29 Implementing Hypothermia 7) Active Hypothermia Program -Monitor results survival neurologic function -Problems will arise patient selection implementation problems -Marathon, not a sprint

30 Thank You

31 Supplementary Materials

32 Patient Selection Presenting Rhythm VT/VF > PEA > Asystole

33 Survival Statistics (%) Inpatient* Outpatient # All Rhythms VF or VT PEA Asystole *Nadkarni VM, et al. JAMA. 2006;295: #Cooper JA, et al.. Circulation 2006;114:

34 Recent Data Survival: OR with hypothermia 2.5 Neurologic Outcome: OR with hypothermia 2.5 Sagalyn et al. Crit Care Med 2009;37: S223-6

35 Non-VT/F Outcomes Hypoth. Historical Oddo % 0.0% Hay % Don % 19.4%

36 Patient Selection Location of Arrest Initial data are for out-of-hospital (should it matter?)

37 Cooling Protocol Mild Hypothermia (32-34 C) hours of cooling ICU environment

38 Pre-Hospital Cooling Several studies show feasibility and safety Do not use if pulmonary edema present 2 L of 4 C Saline or LR cools core temperature 1.5 C

39 Cooling Choices

40 External Cooling Problems: peripheral vasoconstriction and slow cooling, local frostbite, inhomogeneous cooling, frequent overcooling in 2/3 of patients Merchant RM et al. Crit Care Med 2006;34(Suppl.):S

41 Neurologic Evaluation Timing is uncertain Prolonged coma followed by full recovery has been seen Hypothermia may interfere with evoked potentials/n20 response, MRI Holzer M. NEJM 2010;363: Sunde K. et al. Resuscitation 2006; 69 : days in ICU with full recovery after AMI, SCD, hypothermia

42 Costs Per patient: ~$30,000 (includes ICDs) Cost / QALY ~$47,000 (for VT/F arrest) Merchant et al. Circ Cardiovasc Qual Outcomes 2009;2:421-8

43 Complications Holzer M, NEJM 2002;346:

44 Complications Holzer M. NEJM 2010; 363:

45 Implementation Strategies Cardiology Pulmonary/Critical Care Electrophysiology Emergency Medicine and EMS Neurology Hospital Administration

46 Future Research Mechanism: Reactive oxygen, postischemic inflammation, ion flux Expanding indications Timing of initiation Duration of cooling Even more mild hypothermia Advancing post-resuscitation care] Determining prognosis

47 Hemodynamics Bernard S. et al. NEJM. 2002;346:

48 Holzer M, for the Hypothermia after Cardiac Arrest Study Group. NEJM 2002;346: Cooling Curve

49 Accidental Discovery Safar, P. Resuscitation from Clinical Death: Pathophysiologic Limits and Therapeutic Potentials. Critical Care Medicine. 1988;16:

50 Mortality Data Holzer M, for the Hypothermia after Cardiac Arrest Study Group. NEJM 2002;346:

51 Survival From Sudden Death Inpatient* Outpatient # Location Dates included Total # (% survival) % VF or VT (% survival) % PEA (% survival) % Asystole (% survival) % Unknown rhythm USA, Canada 1/00-3/04 36,902 (17.6) 22.7 (36.0) 32.4 (11.2) 35.3 (10.6) 9.6 USA, Canada, England, Norway, Sweden 2/98-6/02, 3/02-10/03, 1/99-12/00 5,234 (6.4) 33.2 (16.1) 24.7 (2.7) 39.0 (0.9) 3.0 *Nadkarni VM, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295: #Cooper JA, et al. Cardiopulmonary resuscitation: History, current practice, and future direction. Circulation 2006;114:

52 Adopting New Interventions

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54 Endovascular Cooling Choices Zoll/Alsius Philips

55 External Cooling Choices Medivance Philips

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