Induced Hypothermia After Cardiac Arrest

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Induced HypothermiaAfter Cardiac Arrest

• Avera Heart Hospital of South Dakota

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Why are we implementing?

• Evidence based practice Endorsed by the
  American Heart Association
• Studies have demonstrated that inducing mild
  hypothermia (32-34 degrees Celsius) in adults who
  have experienced cardiac arrest can decrease the
  effects of reperfusion injury of the brain along
  with decreasing brain O2 demands

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Inclusion/Exclusion Criteria

• Inclusion Criteria
• Cardiac Arrest with ROSC
• Unresponsive after Cardiac Arrest with ROSC
• Endotracheal Intubation w/ mechanical ventilation
• BP can be maintained at least 90 mmHg Systolic
  either spontaneously or with fluid and pressors

• Exclusion Criteria
• Pregnancy
• Another reason for coma (drug overdose, head
  trauma, stroke)
• Known, pre-existing coagulopathy or bleeding
• Down time less than 30-60 minutes most desirable
• Pre-existing DNR/DNI code status
• Purposeful response to verbal commands or noxious
  stimuli after ROSC

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Complications

• Infection
• Coagulopathy
• Hypokalemia (Potassium will shift into the cells
  during cooling)
• Dysrhythmias
• Skin breakdown (monitor for signs of frostbite
  and breakdown)

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Prior to the implementation of the Cooling Process

• Arterial Line Insertion
• Central Line /Swan Ganz (must be placed prior to
  the patient temp reaching 32 Degrees C)
• 2 large peripheral IV s.
• Continuous EKG monitoring
• Access means of monitoring core body temp
  (bladder temp, Swan Ganz, ).
• Train of Four Assessment prior to the initiation
  of neuromuscular blocking agents

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Induction Phase

• Begins in ED with Ice Packs to the groin, axilla,
  and sides of neck .
• PCU- will utilize Blanketrol II hypothermia
  blanket with two disposable blankets
• Place one under patient and one over patient
• Connect to Blanketrol II
• Insert Rectal Temp probe and connect to machine
• Use Auto Mode and set patient temp between 32-34
  Degrees C.

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Induction Phase

• Turn heat off in patients room
• Turn off humidifier on vent, may use heat
  moisture exchanger
• Record time of Induction Phase on Order Set
• Once Induction Phase begins, Central Line
  Placement or manipulation is not recommended
• Vigorous Repositioning of Patient may result in
  ventricular dysrhythmias during Induction and
  Maintenance Phases

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Maintenance Phase

• Patients temperature will be maintained between
  32-34 degrees Celsius.
• Duration of this phase will be 24 hours
• Care of patient during this phase
• Sedation as ordered
• Administer Neuromuscular Blocking Agents as
  ordered to prevent shivering
• Close monitoring of Labs (Electrolytes, BS, CBC,
  Magnesium, ABGs PT, PTT, INR)
• Monitor hemodynamics

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When to Notify MD

• Bradycardia or other arrhythmias
• Significant Bleeding
• UOP less than 30 cc hour
• Hypotension unresponsive to vasopressors

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Documentation

• Induction and Maintenance Phase
• Vital Signs (BP,HR, O2 Sat and Core Body Temp)
• Prior to initiation of Hypothermia
• Q 15 minutes during active cooling
• Q 30 minutes x 4 once therapeutic temp is
  achieved
• Then Q 1 hour during hypothermia

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Documentation

• Cardiac Rhythm will be documented prior to
  initiation, with any rhythm changes and per
  routine
• Urine Output will be documented every hour during
  hypothermia therapy, may resume routine 24 hours
  post hypothermia therapy
• Swan Ganz Reading documented as per routine or
  as ordered
• CVP will be documented every hour during
  hypothermia therapy then routine.

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Rewarming Phase

• Passive Rewarming to begin 24 hours after the
  Induction Phase initiated.
• Passive Rewarming is recommended if patient
  becomes hemodynamically unstable (resistant to
  vasopressors) or develops arrhythmias.
• During passive rewarming the patient should be
  rewarmed no more then 1 degrees Celsius/hour.

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Rewarming Complications

• Hyperkalemia (potassium shifts out of the cell)
• Hypotension (vasodilatation)
• Rebound hyperthermia ( avoid rewarming more than
  1 C per hour)

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Rewarming Process

• Initiate passive rewarming phase by
• discontinue cooling blankets
• Increase ambient room temperature to 68-72F.
• Increase Ventilator humidity to 37 Degrees C.
• May use regular blankets
• The Bair Hugger should only be used if patient
  temp has not reached 36 C after 12 hours of
  passive rewarming.

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Documentation

• Re-warming Phase
• Vital Signs every 15 minutes until 36 C then
  every 30 minutes until normothermia
• Then every 1 hour for 24 hours post hypothermia
  treatment