THERAPEUTIC HYPOTHERMIA

AFTER CARDIAC ARREST:

SHOULD WE START AT

THE EMERGENCY DEPARTMENT

นพ.วินชนะ ศรีวิไลทนต์

ภาควิชาเวชศาสตร์ฉุกเฉิน

คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์

OBJECTIVE

Definition of Therapeutic hypothermia

after cardiac arrest

Benefits of Therapeutic hypothermia

Apply into your emergency department

DISCLOSURE

No disclosures related to this presentation

WHAT IS

THERAPEUTIC

HYPOTHERMIA?

OUTCOME OF OHCA

ROSC

Survival to D/C

THAI 22.5 – 39.2 % 0 – 5.6 %

USA 26.3 % 8.5 – 11.2 %

Europe 33.5 % 10.7 %

Japan 20 – 33.1 % 12 %

CHAIN OF SURVIVAL : AHA 2010

• Immediate recognition and activated EMS (1669)

• Early CPR

• Rapid defibrillation

• Effective ALS

• Integrated Post-Cardiac Arrest Care

MANAGEMENT OF THE PATIENT

AFTER CARDIAC ARREST

Airway

and Breathing

Circulation

Neurological

Metabolic

POST-CARDIAC ARREST SYNDROME

Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome. Resuscitation. 2008;79(3):350-79. Epub 2008/10/31.

• Induce mild therapeutic hypothermia

post cardiac arrest patient that not

response to verbal command with

–Initial EKG was VF arrest

(Class I LOE B)

–Initial EKG was PEA or asystole

(Class IIb LOE B)

Peberdy M, Callaway C, Neumar R, et al. Part 9: Post–Cardiac Arrest Care: 2010 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation 2010;122(18 suppl 3):768-86

BENEFITS OF

THERAPEUTIC

HYPOTHERMIA?

CEREBRAL PERFORMANCE

CATEGORY SCALE (CPC)

Induce mild therapeutic

hypothermia

“solitary treatment that

prove to increase neurological outcome”

RCT 273 patients : 136 in Hypothermia,

137 in Normothermia

Post VF or pulseless VT

MILD THERAPEUTIC HYPOTHERMIA TO

IMPROVE THE NEUROLOGIC

OUTCOME AFTER CARDIAC ARREST

RCT 77 patients : 43 in Hypothermia,

34 in Normothermia

Post VF or pulseless VT

TREATMENT OF COMATOSE SURVIVORS OF

OUT-OF-HOSPITAL CARDIAC

ARREST WITH INDUCED HYPOTHERMIA

Good neurological outcome (normal or with

minimal or moderate disability)

Hypothermia VS Normothermia

= 49% VS 26% (95%CI 13 to 43,P=0.046)

TREATMENT OF COMATOSE SURVIVORS OF

OUT-OF-HOSPITAL CARDIAC

ARREST WITH INDUCED HYPOTHERMIA

EFFECT OF THERAPEUTIC HYPOTHERMIA ON

PATIENTS AFTER CARDIAC ARREST ASSOCIATED

WITH NON-SHOCKABLE RHYTHMS

Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A

Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.

HOW TO APPLY INTO

YOUR EMERGENCY

DEPARTMENT?

PHASE OF INDUCE MILD

THERAPEUTIC HYPOTHERMIA

TEMP

TIME

GOAL

Keep core temperature 32-34C for 12-24 hr.

PHASE OF INDUCE MILD

THERAPEUTIC HYPOTHERMIA

ผศ.นพ.สมบตั ิมุง่ทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac

Arrest Care.ส านกัพิมพ์มหาวิทยาลยัธรรมศาสตร์ 2013:63-76

TIMING TO START THERAPEUTIC

HYPOTHERMIA

Increase short term survival (ROSC)

Not difference in long term

THERAPEUTIC HYPOTHERMIA

IN EMERGENCY DEPARTMENT

TEMPERATURE ON HOSPITAL ADMISSION

SURVIVAL OUTCOME

PHASE OF INDUCE MILD

THERAPEUTIC HYPOTHERMIA

ผศ.นพ.สมบตั ิมุง่ทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. Integrated Post Cardiac

Arrest Care.ส านกัพิมพ์มหาวิทยาลยัธรรมศาสตร์ 2013:63-76

IMPLEMENTATION OF MILD

THERAPEUTIC HYPOTHERMIA

Requires a multidisciplinary approach

Include prehospital personnel, emergency

physicians and staff

Intensivists and ICU staff

Specialists in neurology and cardiology

Invasive techniques Non-invasive techniques

- Infusion of cold intravenous fluid

- Heat exchange catheter

- Extracorporeal circulating cooled

blood

- Intraventricular cerebral hypothermia

- Peritoneal lavage with cool exchanges

- Retrograde jugular vein flush

- Nasal, nasogastric and rectal lavage

- Nasopharyngeal balloon catheters

- Caps or helmets

- Cooling blankets

- Hydrogel-coated cooling pads

- Ice packs

- Immersion in cold water

METHODS TO INDUCE

HYPOTHERMIA

COLD INTRAVENOUS FLUID

HEAT EXCHANGE CATHETER

COOLING CAPS

COOLING BLANKETS

ICE PACKS

ICE PACKS

HYDROGEL-COATED COOLING

PADS

SURFACE COOLING

Simple to implement

Usually take 2-8 hr to achieving goal

temperature

Often combined with additional cooling method

SURFACE COOLING

Hydrogel-coated cooling pads with devices control

temperature through feedback mechanism

More expensive

Mean rate temperature reduction 1.4C/hr

Median time to goal temperature 137 min.

COLD INTRAVENOUS FLUID

Effective in emergency and

prehospital setting

4C Ringer’s lactate solution or normal

saline solution

30 ml/kg or 2,000 ml within 20-30 min

RCT : +4 degrees C Ringer's lactate solution or

conventional fluid therapy

19 in the treatment group and 18 in the control group

At the time of hospital admission

core temperature was lower in hypothermia group

34.1+/-0.9 degrees C vs. 35.2+/-0.8 degrees C, P<0.001

CLINICAL TRIALS ON COOLING

Farid Sadaka. Prehospital Therapeutic Hypothermia for Cardiac Arrest. Mercy Hospital St Louis/St Louis University

REFERENCES

Peberdy M, Callaway C, Neumar R, et al. Part 9: Post–Cardiac Arrest Care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122(18 suppl 3):768-86.

Bryan G, Robert A, Joseph L, et al. Therapeutic Hypothermia for Acute Myocardial Infarction and Cardiac Arrest. The American Journal of Cardiology 2012;03(048):461-66.

Eugene A. Hessel. Therapeutic Hypothermia After In-Hospital Cardiac Arrest: A Critique. Journal of Cardiothoracic and Vascular Anesthesia 2014;28(3):789–99.

Joseph V, Paul E, Sharon E. Therapeutic hypothermia: a state-of-the-art emergency medicine perspective. American Journal of Emergency Medicine 2012;30:800–10.

Hypothermia After Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549 –56.

Bernard S, Gray T, Buist M, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557–63.

Nolan J, Morley P, Vanden T,et al. Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 2003;108:118–21.

Hachimi-Idrissi S, Corne L, Ebinger G, et al: Mild hypothermia induced by a helmet device: a clinical feasibility study. Resuscitation 2001;51:275-81.

Oddo M, Ribordy V, Feihl F, et al. Early predictors of outcome in comatose survivors of ventricular fibrillation and non-ventricular fibrillation cardiac arrest treated with hypothermia: a prospective study. Crit Care Med 2008;36:2296-301.

Hay A, Swann D, Bell K, et al. Therapeutic hypothermia in comatose patients after out-of-hospital cardiac arrest. Anaesthesia 2008;63: 15-9.

Nielsen N, Hovdenes J, Nilsson F, et al. Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 2009;53:926-34.

Steiner T, Meisel F, Mayer S, et al. Therapeutic hypothermia. New York: Marcel Dekker; 2005.

Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest 2008;133:1267-74.

Nolan J, Morley P, Hoek T,et al. Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement Life Support Task Force of the International Liaison committee on Resuscitation. Resuscitation 2003;57:231-5.

ผศ.นพ.สมบัติ มุ่งทวีพงษา. Therapeutic Hypothermia after Cardiac Arrest. In:วินชนะ ศรีวิไลทนต์, บรรณาธิการ. Integrated Post Cardiac Arrest Care.ส านักพิมพ์มหาวิทยาลัยธรรมศาสตร์ 2013:63-76.

Bernard S, Buist M. Induced hypothermia in critical care medicine: a review. Crit Care Med 2003;31:2041-51.

Bloch J, Manax W, Eyal Z, et al. Heart preservation in vitro with hyperbaric oxygenation and hypothermia. J Thorac Cardiovasc Surg 1964;48:969-83.

David S, Marcelo M, Ricardo T. Therapeutic hypothermia after return of spontaneous circulation: Should be offered to all? Resuscitation 2012;83:671– 3.

Jon C, Francis X, Samuel A, et al. Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac arrest. Resuscitation 2008 November;79(2):198–204.

Shashank P, Sadiq B, John M, et al. Therapeutic hypothermia for out-of-hospital cardiac arrest: implementation in a district general hospital emergency department. Emerg Med J 2011;28:970-73.

Barnaby R, Mark D, Kathleen B, et al. Survey of the use of therapeutic hypothermia after cardiac arrest in UK paediatric emergency departments. Emerg Med J 2013;30:24–7.

Galloway R, Sherren P. Therapeutic hypothermia following out-of-hospital cardiac arrest; does it start in the emergency department? Emerg Med J 2010;27:948-49.

Christine E, Shannon C, Aaron A, et al. Therapeutic Hypothermia Protocol in a Community Emergency Department. West J Emerg Med. 2010;11(4):367-72.

Silfvast T, Pettila V. Outcome from severe accidental hypothermia in Southern Finland—a 10-year review. Resuscitation 2003;59:285-90.

Silfvast T, Tiainen M, Poutiainen E, et al. Therapeutic hypothermia after prolonged cardiac arrest due to non-coronary causes. Resuscitation 2003;57:109-12.

Alzaga A, Cerdan M, Varon J. Therapeutic hypothermia. Resuscitation 2006;70:369-80.

Dietrich C, Tobias J. Intraoperative administration of nitric oxide. J Intensive Care Med 2003;18:146-49.

Safar P. Resuscitation of the ischemic brain. In: Albin MS, editor. Textbook of neuroanesthesia with neurosurgical and neuroscience perspectives. New York: McGraw-Hill, Health Professions Division;1997. p. 557-93.

นพ.วนิชนะ ศรีวไิลทนต์. Overview of Post Cardiac Arrest Care and Regionalization of Resuscitation Centers. In:วนิชนะ ศรีวไิลทนต์, บรรณาธิการ. Integrated Post Cardiac Arrest Care.ส านักพมิพ์มหาวทิยาลัยธรรมศาสตร์ 2013:1-13.

Skulec R, Truhlar A, Seblova J,et al. Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline. Crit Care. 2010; 14: R231.

REFERENCES

Bernard S, Smith K, Cameron P. et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation.2010; 122: 737–42.

Bernard S, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med. 2012; 40: 747–53.

Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest. JAMA. 2013;(Nov 17 doi: 10.1001/jama.2013.282173).

Mengyuan D, Fenglou H, Jun G, et al. Prehospital therapeutic hypothermia after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Resuscitation 2013;84:1021–8.

Cabanas J, Brice J, De Maio V, et al. Field induced therapeutic hypothermia for neuroprotection after out-of hospital cardiac arrest: a systematic review of the literature. J Emerg Med 2010.

Varon J. Therapeutic hypothermia and the need for defibrillation: wet or dry? Am J Emerg Med 2007;25:479-80.

Diringer M. Treatment of fever in the neurologic intensive care unit with a catheter-based heat exchange system. Crit Care Med 2004;32:559-64.

Holzer M, Roine R. Hypothermia after cardiac arrest: a treatment that works. Curr Opin Crit Care 2003;9:205-10.

O'Sullivan S, O'Shaughnessy M, O'Connor T. Baron Larrey and cold injury during the campaigns of Napoleon. Ann Plast Surg 1995;34:446-9.

Bell D, Brindley P, Forrest D, et al. Management following resuscitation from cardiac arrest: recommendations from the 2003 Rocky Mountain Critical Care Conference. Can J Anaesth 2005;52:309-22.

REFERENCES

Ryan M, Beattie T, Husselbee K, et al. Use of the infant transwarmer mattress as an external warming modality in resuscitation from hypothermia. Emerg Med J 2003;20:487-8.

Varon J, Acosta P. Therapeutic hypothermia use among health care providers in 2 developing countries. Am J Emerg Med 2008;26:244.

Al-Senani F, Graffagnino C, Grotta J, et al. A prospective, multicenter pilot study to evaluate the feasibility and safety of using the CoolGard System and Icy catheter following cardiac arrest. Resuscitation 2004;62:143-50.

Haugk M, Sterz F, Grassberger M, et al. Feasibility and efficacy of a new non-invasive surface cooling device in post-resuscitation intensive care medicine. Resuscitation 2007;75:76-81.

Virkkunen I, Yli-Hankala A, Silfvast T. Induction of therapeutic hypothermia after cardiac arrest in prehospital patients using ice-cold Ringer's solution: a pilot study. Resuscitation 2004;62:299-302.

Bernard S, Buist M, Monteiro O, et al. 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, Carlbom D, et al. Pilot study of rapid infusion of 2 L of 4 degrees C normal saline for induction of mild hypothermia in hospitalized, comatose survivors of out-of-hospital cardiac arrest. Circulation 2005;112:715-9.

Kamarainen A, Virkkunen I, Tenhunen J, et al. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand 2009;53:900-7.

Farid Sadaka. Prehospital Therapeutic Hypothermia for Cardiac Arrest. Therapeutic Hypothermia in Brain Injury. Mercy Hospital St Louis/St Louis University 35-48.

REFERENCES

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