Pathophysiology and Cardiac Insights for Targeted Temperature Management in Emergency Medicine and Critical Care

Pathophysiology and Cardiac Insights for Targeted Temperature Management in Emergency Medicine and Critical Care LINDSAY LEWIS BSN, RN, CCCC

Faculty Disclosure I AM CURRENTLY EMPLOYED AS A CLINICAL MANAGER WITH BECTON DICKINSON.

Learning Objectives Upon completion of this module, the participant will be able to: Recognize role of Targeted Temperature Management (TTM) Review TTM evidence-based practice Discuss patient management during TTM Identifying and addressing shivering Fever control

Targeted Temperature Management

What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours Field, JM. et al (2010). Circulation. 122(18): S640-S664.

What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM 1. Field, JM. et al (2010). Circulation. 122(18): S640-S664. 2. Neumar, RW. et al (2015). Circulation. 132: S313-S367.

What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32 C and 36 C selected and achieved 1. Field, JM. et al (2010). Circulation. 122(18): S640-S664. 2. Neumar, RW. et al (2015). Circulation. 132: S313-S367.

What s the latest news in the TTM field? 2010 Comatose adult patients with ROSC should be cooled to 32 C to 34 C for 12 to 24 hours 2015 All comatose adult patients with ROSC should have TTM, with a target temperature between 32 C and 36 C selected and achieved, then maintained constantly for 24 hours 1. Field, JM. et al (2010). Circulation. 122(18): S640-S664. 2. Neumar, RW. et al (2015). Circulation. 132: S313-S367.

Targeted Temperature Management (TTM) Prescribed TTM includes dosage and duration Current trends based on recent studies 33 C - 36 C selected and achieved 36 C Hyperthermia control Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206.

What s the latest news in the TTM field? Select and Maintain Specific conditions of the patient may favor selection of one temperature over another Allowing patients to warm above 36 C would be inconsistent with current TTM recommendations Neumar, RW. et al (2015). Circulation. 132: S313-S367.

Four Phases * 37 C 37 C Normothermia 0.25 C / hour 32 C 34 C Maintenance 24 hours 32 C 34 C * Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206.

Four Phases * 37 C 37 C Normothermia 0.25 C / hour 32 C 34 C Maintenance 24 hours 32 C 34 C * Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206.

Four Phases * Time to Initiation 37 C Normothermia 0.25 C / 16hrs 32 C 36 C Maintenance 24 hours * Duration to follow institutional and society guidelines Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206.

preventing ischemic injury is central to all neuroprotective strategies Polderman, KH. (2008). Lancet. 371, 1955-69.

Transient (5 30 minutes) complete or nearly complete lack of blood flow Global Ischemia Lack of blood supply leads to ischemia If blood flow is not restored within 30 minutes, widespread necrosis occurs Polderman, KH. (2004). Int Care Med. 30(4), 556-575. BMD/AS50/0516/0122

Neuronal Damage from Ischemia Complex negative cascade of reactions at cellular level May begin minutes after injury and continue up to 72 hours or longer Chain of events is called secondary injury or reperfusion injury Polderman, KH. (2008). Lancet. 371, 1955-69.

Ischemic Cascade 1-3 Mitochondrial dysfunction Release of excitatory neurotransmitter glutamate Excess release of calcium Disruption of cell membranes Free radical production Blood brain barrier dysfunction 1. Polderman, KH. (2008). Lancet. 371, 1955-69. 2. Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. 3. Malhotra, R. & Lee, K. (2012). The Neuro ICU Book. New York: McGraw Hill Companies, Inc. pp. 188-201.

8 5 2 2 9 6 10 4 3 7 1 2 Alkadri, M. (2009). The Ochsner Journal. 9(4), 278-281.

Key Clinical Considerations* Inhibit neurotransmitter release 1 Inhibit free radical production 1 Reduce oxygen consumption 1 Decrease cerebral metabolic rate (5-8% for every 1 C) 1 Preserve blood brain barrier integrity 1 ICP and cerebral edema are decreased 2 Consider the shivering threshold: dependent on patient s thermoregulatory set point 1,2 Consider the reduction in cerebral metabolic demand 1 May be appropriate for patient population that cannot tolerate 33 C 3 1. Polderman, KH. (2008). Lancet. 371, 1955-69. 2. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 3. Nielsen, N. et al. (2013). N Engl J Med. 369(23), 2197-206. *Follow physician orders and / or your hospital s policies and procedures for selecting target temperature

Physiological Effects of Therapeutic Hypothermia * BP, HR, CO 1-3 EKG Changes Prolonged PR interval 1,2 Widening QRS complex 1,2 Increased QT interval 1,2 J or Osborn wave 1 Cardiovascular *Representative of target temperatures 32-35 C 1. Mehta, S. (2010). PA: HMP Communications. pp. 603-612. 2. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 3. Tischerman, SA. & Stertz, F. (2010). New York: Springer Science. pp. 235-246.

Physiological Effects of Therapeutic Hypothermia * Cardiovascular J Wave or Osborn Wave *Representative of target temperatures 32-35 C Polderman K. (2009). Crit Care Med. 37(7), S186-202.

Physiological Effects of Therapeutic Hypothermia * Hematological 1 Renal Impaired clotting cascade Impaired platelet function: potential increase in bleeding risk Decreased WBC count Diuresis 2,4 Electrolyte loss 3 Gastrointestinal 1 Impaired bowel function / motility *Representative of target temperatures 32-35 C 1. Mehta, S. (2010). PA: HMP Communications. pp. 603-612. 2. Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 3. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 4. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246.

Physiological Effects of Therapeutic Hypothermia * Systemic O 2 consumption and CO 2 production 1,3 Left shift on oxyhemoglobin curve: O 2 is not readily released to the tissues 4 Lactic acidosis 4 Endocrine 1,3 Insulin secretion Immune suppression 1 Infection: wound infections and pneumonia Other 1 Shivering Drug metabolism prolonged *Representative of target temperatures 32-35 C 1. Mehta, S. (2010). PA: HMP Communications. pp. 603-612. 2. Bader MK and Littlejohn LR (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 3. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 4. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246.

Shivering A physiological reflex mechanism that occurs when the body needs to produce or maintain heat The primary center for shivering is found in the posterior hypothalamus Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. BMD/AS50/0516/0122

Mayer, SA. & Sessler, DI. Eds. (2009). Boca Raton: Taylor & Francis Group, p. 5. BMD/AS50/0516/0122

Shivering Involuntary sympathetic response to generate heat 4 Vasoconstriction Piloerection Leads to increased: 1-4 Metabolic rate Metabolic demand Oxygen consumption Carbon dioxide production 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. 3. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 4. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0516/0122

Bedside Shivering Assessment Scale (BSAS) Scale Description 0 No Shivering 1 Mild Shivering, localized to neck and / or chest 2 Shivering, neck and / or chest and <2 extremities 3 Intermittent generalized shivering, >2 extremities Badjatia, N. et al (2008). Stroke. 39(12) 3242-3247. BMD/AS50/0516/0122

Counter Warming May reduce incidence of shivering Tricks skin receptors into believing the body is warm Warm air circulating may be used to cover these areas 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. BMD/AS50/0516/0122

Shivering Management Counter warming is the first line therapy for shivering treatment 1 Sedation prevents increased metabolism 1 Paralytic agents may be used 1-3 Precautions: difficult to identify seizures, select agent with anticonvulsant properties, continuous EEG may be utilized, drug metabolism is affected, appropriate dosing must be tailored to the specific conditions of the patients and must be tightly monitored 1. Mehta, S. (2010). PA: HMP Communications. pp. 603-612. 2. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 3. Lee, K (2012). The NeuroICU Book. New York: McGraw Hill Companies, Inc. p. 192. BMD/AS50/0516/0122

Phases of Therapy Induction Phase Careful monitoring of fluid balance Glucose control Monitor for hypertension Electrolyte management Prevention of shivering General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246.

Phases of Therapy Maintenance Phase Monitor for: EKG changes Bleeding Skin changes Maintain fluid status Infection surveillance Frequent electrolyte monitoring Avoid hyperglycemia General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Mehta, S. (2010). PA: HMP Communications. pp. 603-612. 3. Nunnally, ME. (2010). Mount Prospect: SCCM. pp. 21-27. 4. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246.

Phases of Therapy Rewarming Phase Slow and controlled rewarming (0.01 0.5 C per hour) Rapid rewarming may lead to: Hypoglycemia Increased ICP Rapid electrolyte shifts (hyperkalemia) Sudden vasodilation Cardiac arrest General Considerations: This list may vary depending on the patient s underlying condition. 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246.

Phases of Therapy Controlled Normothermia Phase Fever during the first 72 hours after ROSC has been associated with poor outcome Many clinicians attempt to maintain normothermia (36-37 C) during this time for at least 72 hours after ROSC General Considerations: This list may vary depending on the patient s underlying condition. Seder, DB. & Van der Kloot, TE. (2009). Crit Care Med. 37(7): S212.

Neuroprognostication TTM alters the ability to obtain a clinical neuro exam Drug clearance is decreased so sedatives may be present up to 48-72 hours Decisions regarding withdrawal of care must be delayed until adequate clinical exam can be performed Follow your institution s guidelines for prognostication 1. Bader, MK. & Littlejohn, LR. (2009). AANN Core Curriculum for Neuroscience Nursing. St. Louis, MO: Saunders. pp. 237-246. 2. Guanci, MM. & Mathiesen, C. (2009). Foundations of Neuroscience Nursing. pp. 237-246. 3. Blondin, NA., & Greer, DM. (2011). The Neurologist. 17(5): 241-248.

Summary It is important to properly manage patients receiving targeted temperature management You must be dedicated to shivering control in order to effectively cool patients or to maintain normothermia Fever in critically ill patients is associated with worse outcomes and length of stay BMD/AS50/0516/0122

List of References Badjatia N (2006). Curr Neurol Neurosci Rep. 6(6): 509-517. Badjatia NE, et al (2008). Stroke. 39(12): 3232-3247. Choi A, et al (2010). Neurocrit Care. 14(3): 389-394. Diringer MN, et al (2004). Crit Care Med. 32(7): 1489-1495. English MJ & Hemmerling TM (2008). European J Anaesthesiology. 25(7): 531-537. Greer DM, et al (2008). Stroke. 39: 3029-3035. Mayer SA, et al (2004). Crit Care Med. 32(12): 2508-2515. Merchant R (2006). Crit Care Med. 34(12): S490-S494. Nielsen N, et al (2013). N Engl J Med. 369(23): 2197-206. Peberdy, et al (2010) Circulation. 122(18 Suppl 3): S768-S786. Polderman K (2009). Crit Care Med. 37(7): S186-202. Tomte O, et al (2011). Crit Care Med. 39(3): 443-9. BMD/AS50/0516/0122