mssmem.com

Folks,

I know this is beating a dead horse, but some of us are still cooling patients that are inappropriate and will not benefit from the therapy. The other day I walked in to a patient being hooked up to arctic sun pads that was 83 y/o, with dementia, and possible sepsis. We discontinued hypothermia, signed a FHCDA and got palliative care involved. The patient went up to the floor and was terminally extubated with all of the family present.

This case brings up the need to reiterate the following:

Please don’t cool patients with dementia or sig. cognitive decline.
Please don’t cool patients who can’t manage their ADLs independently
Please don’t cool patients with poor baseline status
Please don’t cool patients with a significant downtime unless they were found in v-fib/vtach
The default is not to cool patients >=80 y/o. I have left this as relative b/c if you have an 80y/o who looks 50 with none of the above, you may want to cool, but the DEFAULT is not to cool these patients
Each use of the arctic sun costs about $2000 in pads; in addition if the ICU continues cooling, the pt will be in the ICU for 5-7 days unnecessarily.

Now let’s say you just can’t handle making this decision. You can’t handle withholding care from ANYONE; it just isn’t in your practice pattern. You have some recourse:

Email Me; if I am around I will call you back immediately and I am happy to take the burden of withholding this therapy
If it is a borderline case, use ICED SALINE and the BLANKETROL machine instead of the arctic sun. If the ICU decides to continue, then they can switch over to arctic sun. If they don’t you have only wasted $100 instead of $2000
Please send me your thoughts and comments.

thanks,
Scott

Please note that the city has entered Phase 2 of Project Hypothermia.  Whereas Phase I focused on instituting hypothermia in the ED and hospital setting for ROSC patients, during Phase II NYC paramedics will be instituting cooling with infused saline during cardiac arrest.

As a result, your cardiac arrest patients should be arriving cooler than they had in the past.  Hopefully this will reduce some of your induced hypothermia workload in your ROSC patients.  Remember to call AMAC and ask for a HYPOTHERMIA alert for any ROSC patient – this will put you in touch with the consulting hypothermia neurologist and should expedite placement in either the CCU or MICU.

Please see the rationale for preservative hypothermia linked here

NYC Project Hypothermia – Rationale for Phase II (Preservative Hypothermia or Intra-Arrest Cooling) Protocol

.

Thanks,

Phil

Hypothermia_04.24.10

Please note that there has been a change in mechanism for disposition of patients treated with therapeutic hypothermia.  In the past, the CCU had been taking all patients, but we have come to the agreement that disposition will be based on etiology not therapy.

Obviously, it may be difficult to determine the most likely etiology of arrest in some patients.  To expedite the ICU triage process for the patients who do not have a clear etiology of their arrest, the units have agreed to have the neurology hypothermia consultant (Frontera or Gordon) in consultation with the ED, decide which unit will take the patient.  The pulmonary and cardiology fellows should be aware of this change.

If there are any difficulties with this process, please notify phil.

Intro: The induction of Mild Therapeutic Hypothermia has been proven to improve mortality and neurological outcomes in survivors of cardiac arrest. This effect is achieved by decreasing cerebral oxygen consumption, suppression of free radical reactions, a reduction of intracellular acidosis and inhibition of excitatory neurotransmitters. The Critical Care community at the Mount Sinai Hospital and Mount Sinai school of Medicine are dedicated to providing this therapy to our patients.

Project Hypothermia: Therapeutic Hypothermia has been provided to appropriate survivors of cardiac arrest at Mount Sinai since April 2008. Mount Sinai is now part of the GNYHA/FDNY/REMSCO city wide initiative to provide this therapy to survivors of cardiac arrest. As part of this effort we are collecting QA data as part of our agreement to collaborate with NY Project Hypothermia. In addition to the standard cooling procedure for our patients you will be asked to complete a very brief form. For your convenience the full protocol, ED worksheet, shivering protocol and QA form are provided here:

• Full MSH Protocol
• ED Post-Cardiac Arrest Worksheet
• Current MSH Shivering Protocol
  

Resources:

• UPenn Center for Resuscitation Science
• Elmhurst Hospital Worksheet
• Weingart EmCrit Hypothermia Page

Lecture: available Navigating the cool waters of hypothermia.

Video: Hypothermia – Getting it Done at emcrit.org

REFERENCES

2002 Studies – the big ones:
Hypothermia after Cardiac Arrest Study Group, (2002). Mild Therapeutic Hypothermia to Improve Neurologic Outcome After Cardiac Arrest. New England Journal of Medicine, 346 (8), 549-556.
Bernard, S., Gray, T., Buise, M., Jones, B., Silvester, M., Gutteridge, M., Smith, K. (2002). Treatment of Comatose Survivors of Out-Of-Hospital Arrest with Induced Hypothermia. New England Journal of Medicine, 346 (8), 557-563.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112[Suppl I]:IV-84-IV-88.
Burns, S. (2001). Revisiting Hypothermia; A Critical Concept. Critical Care Nurse, 21 (2), 83-86.
Ginsberg MD. Hypothermic Neuroprotection in Cerebral Ischemia. In Primer on Cerebrovascular Diseases. 1997:272-275.
Ginsberg MD, Sternau LL, Globus MY, Dietrich WD, Busto R. Therapeutic modulation of brain temperature: relevance to ischemic brain injury. Cerebrovasc Brain Metab Rev 1992; 4:189-22.
Holzer M, Bernard SA, Hachimi-Idrissi S, Hypothermia for neuroprotection after cardiac arrest: systematic review and individual patient data meta-analysis. Crit Care Med. 2005 Jun;33(6):1449-52.
Nolan J, Morley P, Vanden Hoek T, Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advanced Life Support Task Force of the International Liason Committee on Resuscitation (ILCOR). Resuscitation 2003;57:231-235.
Mayer SA, Sessler DI. Therapeutic Hypothermia. New Tyork: Marcel-Dekker, 2005.
Polderman KH. Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality – Part 2: Practical aspects and side effects. Intensive Care Med 2004; 30: 757-769.

Cooling with IV Saline
Bernard S, Buist M, Monteiro O, Induced Hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report. Resuscitation 2003;56:9-13.
Kim F, Olsufka M, Longstreth WT, Pilot Randomized Clinical Trial of Prehospital Induction of Mild Hypothermia in Out-of-Hospital Cardiac Arrest Patients with a Rapid Infusion of 4 °C Normal Saline. Circulation 2007;115;3064-3070.
Polderman K, Rijnsburger E, Peerdeman S, Induction of hypothermia in Patients with various types of neurologic injury with use of large volumes of ice-cold intravenous fluid. Crit Care Med 2005;33:2744-2751.

Shivering Management
Alfonsi P, Sessler D, Dumanoir B. The effects of meperidine and sufentanil on the shivering threshold in postoperative patients. Anesthesiology 1998;89:43-8.
Doufas AG., Lin CM., Suleman MI., Dexmedetomidine and meperidine additively reduce the shivering threshold in humans. Stroke 2 003 May;34(5):1218-23.
Mokhtarani M, Maghoub A, Morioka N. Buspirone and meperdine synergistically reduce the shivering threshold. Anesth. Analg. 2001;93:1223-9.
AHA 2005 Guidelines

Physiology of Hypothermia

Polderman KH.  Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37:7:S185=S294.

Cooling Device Manufacturers:
Alsius Corporation (Irvine, CA; maker of endovascular cooling catheter systems
Innercool Medical (San Diego, CA; maker of endovascular cooling catheter system)
EMCOOLS (Austria; maker of external cooling blanket)
Adroit Medical(Loudon, TN; maker of internal and external cooling devices)
MTRE Advanced Technologies – link from Adroit Medical
Life Recovery Systems (Alexandria, LA; maker of external cooling system)
Medivance, Inc. (Louisville, CO; maker of external cooling system)
Radiant Medical (Redwood, CA; maker of endovascular cooling catheter system)

Hypothermia Research:
The Hypothermia Network
Center for Resuscitation Science (University of Pennsylvania)
Emergency Resuscitation Center (University of Chicago)
European Resuscitation Council
Safar Center for Resuscitation Research (University of Pittsburgh)
The Hypothermia After Cardiac Arrest Registry (European Registry Site)
Food and Drug Administration (FDA) consideration of hypothermia

Hi all,
 
Since FDNY is now following our post-arrest hypothermia cases, it is imperative that we provide optimal care. Four points have come up over the past few weeks:
 
Who does not need hypothermia:
Poor baseline status is a contraindication to induction of hypothermia. Generally if the patient is > 75 y/o, debilitated and/or chronically in a nursing home, they are not a good candidate for hypothermia. A patient with baseline dementia is also not a good candidate. If you cannot ascertain the patient’s baseline mental function and they are >75, it may be better to err on the side of not inducing. These patient groups will not benefit from the thearpy and when they never wake up their inclusion leads to demoralization of the care providers.
 
When we were writing the protocols for NYC, we strongly considered making age over 75, regardless of level of function, a contraindication. We left it out b/c of the rare circumstance of the 80 y/o that looks like they are 60 and have an absolutely prisitine level of function. These patients are rare and do not live in nursing homes, they don’t have contractures, and they don’t have indwelling catheters. I welcome any thoughts or dissenting views on this point.
 
Time of Induction:
In patients who will benefit from hypothermia, it is crucial that induction starts as soon as possible. Every minute wasted decreases the benefits. Get a rectal temp to establish a baseline and then start iced saline right away. Do not wait for a-lines, central access, or any other procedures.
 
Probe Location:
It is all about the esophageal probe. Rectal probe location should only be used if the patient cannot receive a tube down their esophagus.
 
How to get the form:
As soon as ANY post-arrest patient comes in, go to ehced.org under protocols and ENTER THE PATIENTS MEDICAL RECORD NUMBER. This will take you to the form. Do this every time, do not use an old form you had stashed away. Do not enter random numbers just b/c you don’t want to find the MRN> This is critically important, please, please enter the real MRN in order to get the hypothermia instructions form. When the form is filled out, scan it in and then give the original to the ICU resident.
 
tutorials, articles, and videos are up at hypothermia.emcrit.org

Scott Weingart