Curricullum Vitae Dr. Isman Firdaus, SpJP (K), FIHA Email: ismanf@yahoo.com Qualification : o GP 2001 (FKUI) o Cardiologist 2007 (FKUI) o Cardiovascular Intensivist 2010 - present o Cardiovascular Intervensionist 2011 - present Possition : Consultant of Cardiovascular Intensivist in Emergency Instalation and Intensive Cardiovascular Care Unit, Harapan Kita Hospital Critical Care Cardiology Division, Departement Cardiology and Vascular Medicine, University of Indonesia
Post Cardiac Arrest Care in ACS: Role of Therapeutic Hypothermia Isman Firdaus, MD, FIHA Critical Care Cardiology Sub Division Intensive Cardiovascular Care Unit of National Heart Center, Harapan Kita Hospital Departement Cardiology and Vascular Medicine, University of Indonesia
Chain of Survival
Cardiac arrest in the ICU Causes of arrest Metabolic disturbances 29% Shock 26% Hypoxemia 23% Cardiac ischemia 15% Brain death 7% PE 2% Initial rhythms Asystole 47% Brdycardia followed by asystole 29% PEA 18% V Fib/V Tach 6% Hospital survival is 11% Critical care, 2001
Cardiopulmonary Resuscitation on TV 97 episodes of ER, Chicago Hope and Rescue 911 reviewed 60 incidents of Cardiac arrest observed Etiology of cardiac arrest 55% trauma,28% cardiac 75% of patients survived the immediate arrest 68% survived to hospital discharge 10 cases had miraculous recovery when physicians gave up hope. Almost all patients surviving had normal neurolgic and functional outcome. NEJM 1996 :334 (1578-82)
Outcome of in-hospital cardiac arrest National Registry of Cardiopulmonary Resuscitation (NRCPR) of 14720 in-hospital arrests with 17% hospital discharge. 16% of patients had V Fib as initial rhythm with 34% hospital discharge 105 patients with in-hospital arrests reviewed.44% survived the arrest and 22% survived to discharge Better prognosis Cardiac etiology V Tach or V Fib Internal Medicine Journal 34 ; 398 - July 2004
Survival According to Initial Rhythm Critical care medicine 1999
Can the outcome of cardiac arrest be improved??
The Use of Hypothermia After Cardiac Arrest 60 Comatose survivors Asystole or VF 31-32 C Cooling until neurologic recovery (3 hours to 8 days) Water-filled blanket % 50 40 30 20 10 0 Favorable neurologic recovery Hypothermia (n=12) Normothermia (n=7) Benson et al,anesth Analg 1959; 38: 423-8.
Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest (HACA) Patients with witnessed cardiac arrest from VF or pulseless VT, 18-75 years of age, estimated 5-15 minutes to attempted resuscitation, and less than 60 minutes from collapse to restoration of spontaneous circulation (ROSC). 275 patients of 3,551 cardiac arrests screened were eligible for the study (8%) 137 patients randomized to receive hypothermia (32-34 c) for 24 hours Dr. Fritz Sterz, Vienna, Austria, and The Hypothermia After Cardiac Arrest Study Group, N Engl SymCARD J Med 2013 2002; Padang-West 346:549-556 Sumatera 17-
HACA Study Group Randomized trial 2002 -Hypothermia vs Normothermia Methods Inclusion - CA due to VF Exclusion cardiogenic shock Hypothermia group 32 C - 34 C Cooled for 24 hrs Rewarming over 8 hrs 3246 ineligible 3351 assessed 30 Not included 137 hypothermia 275 enrolled 138 normothermia Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.
HACA Study Group Neurologic outcome Pittsburgh cerebral performance category scale Cerebral Performance Category (CPC) Positive Outcomes Negative Outcomes CPC 1 CPC 2 CPC 3 CPC 4 CPC 5 Good cerebral performance Moderate cerebral disability Severe cerebral disability Coma or vegetative state Brain death
Hypothermia for Coma After Cardiac Arrest P 0.02 Hypothermia Normothermia Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.
Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest (HACA) Mortality at 6 months was 41% in the hypothermia group and 55% in the normothermia group 55% of hypothermia group and 39% of normothermia group had a favorable neurologic outcome (good recovery or moderate disability) p value 0.009 Complication rate did not differ significantly between the two groups Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549-556.
Treatment of Comatose Survivors of Cardiac Arrest with Induced Hypothermia Survival was 21/43 of the hypothermia group (49%) vs. 9/34 treated with normothermia (25%) p = 0.01 Good outcome (normal or with minimal or moderate disability) was 49% in hypothermia group and 26% in the normothermia p = 0.046 Bernard et al. (Australia), N Engl J Med 2002; 346:557-563
Favorable Neuro Outcome :All three studies combined Benson 1959 50% with Hypo (12) 15% with Normo (7) HACA 2002 55% with Hypo (137) 39% with Normo (138) Bernard 2002 49% with Hypo (43) 25% with Normo (34) Total patients: Hypo = 192 Normo = 179
Combined Data (3 studies) Favorable Neuro Hypothermia = 53% (102/192) Normothermia = 35% (63/116) Chi Square Testing: p < 0.0005
Cooling Experience in Indonesia??
Therapeutic Hypothermia in Harapan Kita Hospital August 2011 March 2012 value Cardiac Arrest Patients 27 Male 23 (85.3%) Age 61 + 12 yo Emergency 14 (56%) Ward 5 (12%) Cathlab 6 (24%) EF 35.4 + 15.5 % STEMI 12 (44%) Non STEMI 3 (11%) Reperfusion for STEMI PPCI 4 (33.3%) Fibrinolitic 2 (16.6%) Without reperfusion 6 (50%) Length of stay in ICCU 6.5 +11.9 days Survived to discharge after SymCARD cardiac 2013 Padang-West arrest Sumatera 17-14 (61%)
AHA guidelines for ACLS and post CPR care In a select subset of patients who were initially comatose but hemodynamicaly stable after a witnessed VF arrest of presumed cardiac etiology, active induction of hypothermia was beneficial. Thus, unconscious adult patients with ROSC after out-of-hospital cardiac arrest should be cooled to 32 C to 34 C for 12 to 24 hours when the initial rhythm was VF (Class IIa). Similar therapy may be beneficial for patients with non-vf arrest out of hospital or for in-hospital arrest (Class IIb). 2005 AHA guidelines, Circulation 2010 AHA guideline, ACLS Updated
Post Cardiac Arrest Care Program AHA Guideline 2010 Therapeutic hypothermia Optimization of hemodynamics and gas exchange Immediate coronary reperfusion when indicated Glycemic control Neurological Diagnosis, management, and prognostication.
How to apply hypothermia??
Four Modes of Heat Transfer Conduction Cold water immersion Radiation Cold room Convection Fans (do not use for infection control purposes) Evaporation Sweating
Basics of Therapeutic Hypothermia: Three phases of treatment Induction Rapidly bring the temperature to 32-34C Sedate with propofol or midazolam during TH Paralyze to suppress heat production Maintenance maintain the goal temperature at 33C Standard 12-24 hours (optimal duration is unknown) Suppress shivering Rewarming Most dangerous period: hypotension, brain swelling, Goal is to reach normal body temperature over 12-24h Stop all sedation when normal body temperature is achieved
Induction: How to Cool Commercial cooling devices Servo mechanism varies temperature of circulating water or air (prevents overcooling) External (surface cooling) systems Hydrogel heat exchange pads Cold water circulating through plastic suit Cold water immersion awaiting safety data Invasive (catheter based) systems Heat exchange catheter in SVC or IVC Plastic or metalic heat-exchange catheter
Cooling Devices
Management of shivering Neuromuscular blockade Vecuronium bolus 0.1mg/kg prn BSAS>2 Cisatricurium in renal failure Propofol Alpha blockade Dexmedetomidine infusion or clonidine Scheduled acetaminophen, buproprion Meperidine or fentanyl Focal counterwarming Magnesium infusion (serum level 3mg/dl)
Re-warming If using surface cooling: Use passive re-warming Remove Ice packs Stop cold Iv fluids If using endovascular cooling: set temperature rise at 0.3-0.5 degrees per hour Avoid rapid re-warming
Maintainance: how to cool Monitor core temperature Bladder, esophagus, or central venous/pulmonary arterial Ice packs and cooling mats Effective, but difficult to control rate of temperature change Overcooling is dangerous Endovascular cooling allows for gradual reduction in temp, maintainence at desired temp and prevents over cooling
Take home messages Strong evidence that mild hypothermia is neuro-protective after return of spontaneous circulation Hypothermia is underutilized so far but should be included in post resuscitaion care of cardiac arrest victims
...The Last but not Least... كل نفس ذائقة الموت...Setiap yang hidup pasti akan mati...
Hypothermia Questions How to monitor cooling? Bladder, rectal or blood temperature? Brain temperature? How should we manage shivering? If use NMB, need to monitor EEG Sub-clinical seizures may be more common than clinically recognized should we load with anticonvulsants? How to adjust medications in the hypothermic patient Are there useful biomarkers?