Shyama Marshall RN, BSN Clinical Nurse II, Neuroscience ICU UCI Medical Center 1
Introduction/Background One of the challenges to registered nurses is hypothermia in burn ICU patients and uncontrollable fever in neuropatients and post-cardiac arrest patients. Maintaining temperature in these patients to a therapeutic level with conventional methods is very challenging. Uncontrolled temperature has a direct/indirect effect on the patient outcome Shivering and abnormal temperature, uncontrolled by conventional methods, have unknown effects on the patient s recovery. Thermogard will aid patient s recovery through the neuroprotective effects of induced hypothermia/normothermia 2
Thermogard-induced hypo or normothermia: Introduction Improves neurological outcome in neuro and postcardiac arrest patients By regulating pt s temp. Thermogard lessens pt s length of hospital stay, requires less nursing interventions and is therefore cost-effective. Thermogard is a machine from which cooled sterile saline flows through the central line catheter thereby regulating pt body temp. without direct contact of saline with the pt s blood.
Goals of Project: Familiarize nursing staff with the current research on the use of normothermia and induced hypothermia. Help patients to recover with less neurological damage by controlling or maintaining target temperature. Reduce patient s temperature-related complications. Reduce skin-related issues, common in conventional fever-reducing methods Familiarize nursing staff with the use of Thermogard. Increase and improve staff knowledge, competency and confidence in using the Thermogard for induced hypothermia and normothermia. 4
Methodology Educational in-service /Class for nurses Train super-users Train the trainer for inpatient nurses on the use of Thermogard Develop a competency checklist Develop a pre and post-inservice/class test Develop guidelines and order sets on the use of Thermogard -therapeutic hypothermia and normothermia. 5
What are the current guidelines? Cardiac Arrest- out of hospital Adult patients who are comatose with spontaneous circulation after out-of-hospital VF cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 hours. Executive Summary 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 6
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Current Stroke Guidelines The 2007 AHA guidelines recommend keeping the patient normothermic (Level 2; Adams et al., 2007). 8
Current Stroke guidelines Temperature should be monitored. Temperature elevation has been associated with increased mortality and morbidity in an acute stroke. The fever increases metabolic demands of the brain, which can worsen the ischemia and lead to further tissue damage. 9
In the stroke population, hyperthermia within the first 24 hours correlates with a mortality rate of 78%, compared with 2% in normothermic patients (Castillo et al., 1994). 10
Stroke Guidelines Research is studying the use of hypothermia for acute stroke and head injury, but data supporting its use are insufficient Guide to the Care of the Hospitalized Patient with Ischemic Stroke 2nd Edition, Revised AANN Clinical Practice Guideline Series 11
Brain Trauma Foundation issued Level 3 recommendation in 2008 Cautious use of induced hypothermia The analysis suggests that hypothermia maintained for more than 48 hours reduces mortality and results in favorable neurological outcomes when they are measured 1 2 years post injury 12
Maintaining Normothermia May Prevent ICP Increases (Level 2) There have been no long-term outcome studies on the effects of normothermia in a TBI population. One descriptive study of 20 patients, 10 of whom sustained acute TBI, found an increase in brain temperature was associated with a significant rise in ICP; (Rossi, Zanier, Mauri, Columbo, & Stocchetti, 2001). 13
Burn Research: Improves comfort level, allows for longer surgical procedures. Facilitates wound debridement, excision and grafting in burn patients and also minimizes complications
Conventional Cooling Methods Conventional cooling methods and therapies in use have led to inconsistency in controlling/maintaining patient s temperature in a desired range: External warming methods External cooling methods A) tepid sponge B) ice packs to axillae, groins, cranio-cervical areas C) cold saline or ice water lavage through NG tube. D) cooling blanket -anterior and posterior E) anti-pyretic drugs 16
Use of the Thermogard NK8s, Thermogard.pdf
Research Questions Intravascular temperatrure regulation (induced hypothermia) is it the right way to minimize the neurological or cardiac complications? Does it increase the survival rate? Mild or moderate hypothermia. Which is the option for achieving the right temperature to minimize or improve neurological and cardiac outcomes? Does therapeutic hypothermia or normo thermia prevent secondary brain injury and provide neuro protection? Mild or moderate or deep hypothermia for whom? When do we start? (timing) What is the duration? Does it improve survival rate by preventing secondary complications in stroke and cardiac arrest patients?
Hypothesis We should be cooling in-hospital cardiac arrest patients as well as out of hospital cardiac arrest patients Induced hypothermia in the TBI and Stroke patient will improve neurological outcomes and decrease mortality- need further research to support these statements
Conclusion Studies have shown that there is a correlation between body temperature and initial stroke severity,infarct size, outcome and mortality. In cerebral ischemic patients, small changes in the temperature of the ischemic brain tissue may alter survival of neurons. Excitatory amino acids, oxygen free radicals and inflammatory cytokines appear within minutes of brain injury/ischemia and lead to secondary brain injury. If Therapeutic Hypothermia is induced in such patients without any delay, its mechanism of action reduces the levels of these mediators of secondary brain injury. But requires more research. Should we use Therapeutic temperature regulation with Thermogard to manage our pts temperature and prevent secondary complications in Post Cardiac Arrest pts, Neuro pts and Burn pts?
Literature Reviewed Critical Care Nurse, Induced hypothermia for Patients with cardiac arrest: Role of Clinical Nurse Specialist. (2007). 27,5, 36-42 http://cln.aacnjournals.org King B, Corallo J.P. & Luo, X. (YEAR) Using an intravascular warming catheter to maintain normothermia during burn excision. UNMSM, University of Miami, J.M. Hospital Nolan, J.P., Morley,P.J. et al. Therapeutic Hypothermia after cardiac arrest: an advisory statement by the Advanced Life Support Task Force of the International Liason Committee on Resuscitation Circulatory Journal of the American Heart Association.( 2003) 108, 118-121 American Heart Association. Granville Avenue, Dallas TX (2010, April 1) LA marathon cardiac arrest victim doing well after induced hypthermia treatment at UCLA http://newsblaze.com/story201/topstory.html Branes, E.B., Gomez-Bajo, G.J. et al. (2003) Hypothermia and Burns: a meta-analysis. Annals of Burns and Fire Disasters. XVI, June, No.2 (PAGE???) Broessner G. et al. Prophylactic, Endovascularly-based, Long-term normothermia in ICU patients with cerebrovascular disease. Retrieved April 30, 2010, from http:// stroke.ahajournals.org/cgi/cont/ fill /40/12/e657. Neeraj, B. (2009) Fever control in the Neuro-ICU: why, who and when? Current Opinion in Critical Care Vol. 15, April, Issue 2, pp. 79-82. Retrieved in 30 April 2010 from http://journals.iwco.com/co-criticalcare/fulltext/2009 Paccio, M.A., Fischer, R.M. et al. Induced normathermia attenuates intracranial hypertension and reduces fever burden after severe traumatic brain injury. Journal of Neuro-critical Care Vol. 11, No. 1, August 2009 PAGE NUMBERS Shivering Avoidance in the Neurally-Injured Patient: Impact on Temperature Management Technology Decisions. Retrieved from www.alsices.com www.alsius.com Research Comparison of cooling methods to induce and maintain normo and hypothermia in intensive care unit patients: a prospective intervention study. Aug 24, 2007. Critical Care 2007, Vol 11:R91. Retrieved from http://ccforum.com/contact/11/4/r91/2007 Romes, G.E., Rester, M et al. (2002)Periopatric Hypothermia in Burn Patients subjected to non-extensive surgical procedures. Annals of Burns and Fire Disasters. Vol. XV. No. 3 September 2002 Hicky, J.V. (2003) The Clinical Practice of Neurological and Neurosurgical nursing (5 th Ed) Lippincott Philadelphia Nettina, M.S. (2001) Manual of Nursing Practice (7 th Ed) Lipincott Philadelphia Bader, M.K., & Littlejohns, L.R. (2004) AANN Core Curriculum for Neuroscience Nursing (4 th Ed) Elsiever Inc St Louis Missouri Mayer, S.A., & Sessler, D.I. (2005) Therapeutic Hypothermia. Marcel Dekker, New York
Literature Reviewed[contd.] Puccio & Fischer et al Induced Normothermia Attenuates Intracrnial Hypertonin and Reduces fever burden after severe traumatic Brain Injury Neurocritical Care (2009) 11:82-87 Neurocritical Care Society published on 1 April 2009 dept of Neurological Surgery University of Pittsburg Medical Center ALSIUS reference www.alsius.com. Tel 1-877-2ALSIUS Alsius Operating Manual Lasater, M. Treatment of Severe Hypothermia with Intravascular Temperature Modulation Critical Care Nurse Vol 28, No 6 Dec 2008 http://ccn.aacnjournals.org Center for Disease Control and Prevention. Hypothermia - related monthly Montana 1999-2004 MMWR Mob Mental Wkly Rep 2007; 56(15): 367-368 O Grady, P.N. & Barrie, S.P. et al (2008) Guidelines for Evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Critical Care Med 2008 Vol.36 No 4 Lippincott Williams & Wilkines Leaper, D. & Kumar,S. et al. Maintaining Normothermia During Surgery. Retrieved on 8/26/10 at http://www.hosintint.net/categories/hypothermia/maintaining_normothermia_during_surgery Glance@Vancouver hospital themes and protocols for hypothermia/n Muchelberger,T. & Ottoman, C. et al. Emergency Pre-hospital care of burn patients. The Surgeon 8 (2010) 101-104 Elsevier. Retrieved at www.thesurgeon.net Corallo, J.P. Core Warming of a burn patient during excision to prevent hypothermia. Burns (2007) doi 10.1016/J.Burns.2007.08.012 Brunas, B.E. et al. Hypothermia and Bruns: A meta-analysis. Annals of Burns and Fire Disasters. Vol. XVI-n.2 June 2003. Retrieved on 8/26/10 http://www.medbc.com/annals/review/vol 16/normz/text/vol16n2p77.asp US Healthcare Initiatives Turn Focus to Normothermia. www.cdc.gov www.ihi.gov. www.apic.org www.jointcommission.org www.acc.org www.asper.org www.americanheart.org www.aorn.org www.americanheart.org www.asatiq.org www.arizort.com 22