Appendix. Critical Pathway of Brain Hypothermia Treatment978-4-431-53953-7/1.pdf · Appendix....

Appendix. Critical Pathway of Brain Hypothermia Treatment

1. Mild brain hypothermia treatment (34°C)

Indication: GCS 6-9, unstable vital signs, insulin-resistant hyperglycemia Induction: within 3-6 h Duration: 2-7 days

\ ----~~ 3~C ,-

------~ One step induction

2. Moderate brain hypothermia treatment (32°-33°C)

Indication: GCS 6-4, hemiated patient after controled vital signs and hyperglycemia Induction: within 3-4 h Duration: 4-14 days

Two step induction Intermittent hypothermia

Preconditioning

Contraindication Severity: GCS=3, brain death

Adaptation time

Pathophysiology: shock, MOF, severe infections, cardiac insufficiency, arrhythmia Disease: uncontrollable subarachnoid hemorrhage Time: >6 h, >24 h (time dependent) Age: ?

291

N

\D

N >- "0

"0

(1)

~ ~ (")

Out

line

of t

he c

ritic

al p

ath

of b

rain

hyp

othe

rmia

tre

atm

ent

:J.

..... n·

Sta

ge

Sta

ge 1

S

tage

2

Sta

ge 3

S

tage

4

Sta

ge 5

S

tage

6

~

'"0

Indu

ctio

n 1

Indu

ctio

n 2

Coo

ling

Pre

cond

ition

ing

Rew

arm

ing

Pos

t hy

poth

erm

ia

~ So

:IE

Dur

atio

n 3

h

6h

3

-7 d

ays

1-2

day

s 1

-2 d

ays

3-4

wee

ks

~

'<

0 A

lgor

ithm

of

Ho

to

Man

agem

ent

Sta

biliz

e vi

tal s

igns

M

ild o

r m

oder

ate

Inte

rmitt

ent

Evi

denc

e of

neu

rona

l S

tep

by s

tep

rew

arm

A

10-

Dop

amin

e .... ~

Tar

gets

S

hive

ring

hypo

ther

mia

? hy

poth

erm

ia

reco

very

A

dapt

atio

n tim

e re

plac

emen

t th

erap

y S·

C

atec

hola

min

e S

erum

glu

cose

IC

P <

15

mm

Hg

N

o se

vere

inf

ectio

n S

erum

glu

cose

R

esto

ratio

n th

erap

y o

f ::r: '<

su

rge

<1

60

mg

/dl

Bra

in e

dem

a C

SF

/ser

um a

lbum

in

13

0-1

50

mg/

dl

vege

tatio

n "0

0

Neu

rona

l hy

poxi

a D

02

>70

0 m

Vm

in

AT

-III

>10

0%

<0.0

1 0

02

>7

00

ml/m

in

Neu

rore

habi

litat

ion

.....

::r-H

yper

glyc

emia

H

emog

lobi

n S

erum

alb

umin

S

erum

glu

cose

0

2 ER

23

-35

(1

) .... 34

°C b

rain

dy

sfun

ctio

n >

3.5

mg

/dl

12

0-1

40

mg/

dl

Pa

C0 2

32-

36 m

mH

g 8. ~

tem

pera

ture

A

T-III

>10

0%

Imm

une

Ent

eral

nut

ritio

n S

erum

pH

7.3

-7.4

::;l

D

opam

ine

rele

ase

Hyp

opot

asse

mia

dy

sfun

ctio

n R

ecov

er im

mun

e S

erum

Pho

spha

te

(1) ~

Rad

ical

rea

ctio

n S

BP

> 1

00

mm

Hg

P

reve

nt i

nfec

tion

func

tion

>3

mg

/dl

.....

S F

luid

res

usci

tatio

n A

ctiv

ate

lipid

A

ctiv

ate

lipid

S

erum

Mg

' >

1.3

mm

ol/d

l (1

) ~

met

abol

ism

m

etab

olis

m

Rep

lace

men

t vi

tam

in A

.....

I n

fect

ion

cont

rol

Sta

ndar

d M

anag

emen

t O

rder

B

asic

car

e pl

an

CD

CD

CD

CD

CD

CD

Car

e or

der

~

~

~

~

~

~

Inte

rven

tion

@

@

@

@

@

@

IV m

edic

atio

n @

) @

) @

) @

) @

) @

)

Mon

itor

Bra

in m

onito

r @

@

@

@

@

@

S

yste

mic

car

e ®

®

®

®

®

®

m

onito

r

Appendix. Critical Pathway of Brain Hypothermia Treatment 293

Stage 1.1.

Basic care plan:

• Start brain hypothermia within 3 h after insult. • Maintain the systolic blood pressure> 100 mmHg. • Evaluate GCS < 8 and surgical indication. • Rapid management of stress-associated hyperglycemia. • Maintain hemoglobin function with control of serum pH, phosphate, and magnesium. • Prevent catecholamine surge. • Neuronal oxygenation. • Prevent enterobacterial infection. • Suppress hypothalamus dopamine release.

Stage 1.2.

Care order:

• Systolic blood pressure (SBP): control at 120-160 mmHg by fluid resuscitation. • SBP > 170 mmHg hypertension: drip the antihypertensive drug, diltiazem hydrochlo-

ride (Helvesser), 250 mg, diluted with 100 ml saline at 2 ml/h. • Blood gases: Pa02> 100 mmHg, PaOiFi02 ratio> 350, PaC02 34-38 mmHg. • Urine: maintain at 0.5 ml/kg h-1•

• Serum glucose: control serum glucose at 120-140 mg/dl by drip of rapid - action insulin (Humarin R), 50 U diluted with 100 ml saline. * Administration speed: start from 2 ml/h and then slow down to 1 ml/hour after serum

glucose becomes lower than 200 mg/dl. • Serum potassium: control at 3.5-4.5 mEq/1 by drip of KCI 1 A, diluted with 80 ml saline.

* Replacement speed 40 ml/h for serum K+ < 2.0 mEq/1. * 20 mllh for serum K+ 1.2-2.5 mEq/1. * 15 ml/h for serum K+ 2.6-3.0 mEq/1. * 10 ml/h for serum K+ 23.1-3.05 mEq/1. * 5 ml/h for serum K+ 3.6-34.0 mEq/1.

294 Appendix. Critical Pathway of Brain Hypothermia Treatment

Stage 1.3.

Intervention:

• Bronchial intubation and ventilator care management. • Fluid resuscitation by central venous catheterization. • Catheter insertion for monitoring arterial blood gases. • Insertion of naso-gastric tube. • Insertion of Foley catheter for urinary drainage. • Monitoring of ECG. • Biochemical analysis. • Blood type. • X-ray examination. • Gastric lavage. • Digastrics decontamination.

* One shot enteral administration of nonabsorbable antibiotics: levofloxacin (Cravit, 200 mg) + amphotericin B, 100-300 mg.

Stage 1.4.

Intravenous medication:

• Fluid resuscitation: 7% Acetic acid Ringer solution (Veen F) and Saline Hess solution at induction stage, except hypoglycemia. The replacement of potassium phosphate, vitamin A, vitamin S, Mg++, 5% albumin, and AT-III are recommended.

• Crush induction of anesthesia: midazolam 0.15-0.25 mg/kg h-1 anesthesia, combined with pancuronium 0.05 mg/kg h-1 muscle relaxation, and buprenorphine 1.0-2.0 mg/kg h-1 analgesia. Propofol is much better for unstable cardiopulmonary function than midazolam. At the beginning of the induction stage, propopfol is preferred.

• Management of aspiration pneumonia: first choice is panipenem betamipron (Carbenin 500 mg x 2/day), second choice is ceftazidime (Modasin 1 9 x 2/day) or clindamycine (Dalacin, 150-300 mg per 6 h) + one-shot enteral administration of nonabsorbable antibiotics: levofloxacin (Cravit, 200 mg) + Amphotericin S, 100-300 mg to prevent Pseudomonas aspiration pneumonia and enteral bacterial translocation.


Stage 1.5.

Brain monitoring and management:

• Computed brain monitoring: * Tympanic membrane temperature/core temperature> 1.0. * Internal jugular venous blood temperature/tympanic membrane temperature> 1.0. * Ventricular CSF temperature/internal jugular venous blood temperature> 1.0. * Ventricular CSF temperature/bladder temperature> 1.0.

• ICP < 20 mmHg. • Microdialysis monitoring. • Sj02> 60%. • CPP > 80 mmHg. • Trend EEG. • Auditory brain stem evoked response (ABER).

Stage 1.6.

Monitoring and management of systemic hemodynamic changes:

• SBP> 100mmHg • Monitoring of ECG for arrhythmia, ST changes, and QT interval < 450 mm/s. • Right flowing catheter monitoring of cardiac output (CO). • Cardiac index (CI). • Oxygen delivery> 700 ml/min. • Oxygen extraction ratio (02ER) 22%-26%. • Bladder pressure < 15 mmHg. • Gastric pHi> 7.3. • Intestinalluminar pressure < 15mmHg. • Serum glucose and hemoglobin A 1 C. • AT-III. • Hemoglobin. • Serum albumin. • Troponin I and CPK. • GOT and GPT.

• Ht. • Serum osmolarity. • Creatinine.

Sta

ge

1. A

lgo

rith

m m

anag

emen

t

• S

tabi

lize

vita

l si

gns:

ela

stic

ban

dagi

ng o

f ex

trem

ities

, no

rmal

vol

ume

repl

acem

ent,

med

icat

ion,

mai

ntai

n S

BP

>

10

0m

mH

g,

CP

P>

80

mm

Hg

, H

b>

12m

g/dl

, ox

ygen

de

live

ry>

800

ml/m

in.,

2,3

-DP

G >

13J

.lmol

/ml.

• S

erum

K+

> 3

mE

q/dl

, se

rum

glu

cose

12

0-1

40

mg

/dl.

• S

hive

ring:

mid

azol

am a

nest

hesi

a 0

.15

-0.2

5 m

g/kg

h-1

co

mbi

ned

with

pan

curo

nium

mus

cle

rela

xant

0.0

5 m

g/kg

h-1

,

and

bupr

enor

phin

e an

alge

sia

1.0

-2.0

mg/

kg h

-1•

• C

atec

hola

min

e su

rge:

con

trol

of

cate

chol

amin

e su

rge

by c

ontr

ol o

f br

ain

tissu

e te

mpe

ratu

re a

t 34

°C

, adm

inis

tra

tion

of m

etoc

lopr

amid

e.

• N

euro

nal

hypo

xia:

Pa

OiF

i02

ratio

> 3

50,

hem

oglo

bin

DP

G:

12-1

4J.lm

ol/m

l, ox

ygen

de

live

ry>

700

ml/m

in,

CP

P>

80

mm

Hg,

AT

-III

> 1

00%

. •

Hyp

ergl

ycem

ia:

adm

inis

trat

ion

of i

nsul

in w

ith c

ontr

ol o

f se

rum

pho

spha

te a

nd m

agne

sium

. •

7% a

ceta

te R

inge

r so

lutio

n.

• S

tero

id c

ontr

aind

icat

ed.

• A

ctiv

ate

resp

irato

ry m

uscl

e m

etab

olis

m w

ith a

lbut

amol

. •

Rap

id i

nduc

tion

of m

ild b

rain

hyp

othe

rmia

: co

mbi

natio

n of

bla

nket

coo

ling

met

hod

and

gast

ric l

avag

e w

ith c

hille

d sa

line,

alc

ohol

hea

t ev

apor

atio

n, c

ompl

ete

body

wra

ppin

g an

d in

sula

tion

from

roo

m a

ir, r

educ

e ro

om t

empe

ratu

re

to 1

8°C

, mai

ntai

n ro

om a

ir ou

tflow

circ

ulat

ion,

tw

o co

olin

g m

achi

nes,

rem

ove

heat

gen

erat

ing

med

ical

dev

ices

fro

m

the

beds

ide.

•

Dop

amin

e re

leas

e: e

arly

ind

uctio

n of

bra

in h

ypot

herm

ia a

nd a

dmin

istr

atio

n of

met

oclo

pram

ide.

•

Pre

vent

ion

of r

adic

al

reac

tion:

ear

ly i

nduc

tion

of m

ild b

rain

hyp

othe

rmia

and

con

tinue

to

mod

erat

e br

ain

hypo

th

erm

ia.

• C

ontr

ol o

f H

b >

11

mg/

dl,

adm

inis

trat

ion

of v

itam

ins

E a

nd C

.

tv

'D

0\ ~

"0

(1) ::::s &.

?< (J

::l. g. e:..

"'0

I'l ;.

~ ~ o '"" ttl .., I'

l Er ~ o .... p

(1

) §l s;.

~

(1)

I'l a (1) g


Stage 2.1.

Basic care plan:

• Select mild or moderate brain hypothermia. • Monitor internal jugular venous temperature. • Monitor ventricular CSF temperature. • Monitor tympanic temperature. • Monitor core temperature. • Monitor bladder temperature. • Stabilize vital signs for induction to moderate brain hypothermia. • SSP> 100mmHg. • Treat hypokalemia. • Ensure no arrhythmia. • QT-interval < 450 mm/s on ECG. • Serum glucose 120-140 mmHg. • Brain monitoring, Sj02 65%-80%. • ICP < 20 mmHg.

Stage 2.2.

Care order:

• Systolic blood pressure (SBP): 120-160 mmHg by fluid resuscitation. • SBP> 170 mmHg hypertension: drip antihypertensive drug diltiazem hydrochloride (Helvesser), 250 mg,

diluted with 100 ml saline at 2 ml/h. • Complication of bradycardia (HR < 50 bpm): nicardipine hydrochloride (Perdipin) 2-5 ~g/kg min-1 .

• Blood gases: Pa02> 100 mmHg, PaOiFi02 ratio> 350, PaC02 35 mmHg. • Urine volume: more than 0.5 ml/kg h-1 .

• Serum glucose: 120-140 mg/dl by drip of rapid-action insulin (Humarin R) 50 U diluted with 100 ml saline. * Administration speed: start at 2 ml/h and slow to 1 ml/h after serum glucose falls below 200 mg/dl.

• Serum potassium: control at 3.5-4.5 mEq/1 by drip of KCI 1 A, diluted with 80 ml saline. * Replacement speed: 40ml/h for serum K+ < 2.0mEq/l.

20 ml/h for serum K+ 1.2-2.5 mEq/1. 15 ml/h for serum K+ 2.6-3.0 mEq/1. 10ml/h for serum K+ 23.1-3.05mEq/l. 5 ml/h for serum K+ 3.6-34.0 mEq/1.


Stage 2.3.

Intervention:

• Ventilator management. • Ventricular drainage. • ICP monitoring. • Sj02 monitoring. • Monitoring cardiac output and 02ER. • Body weight. • Blood gases. • Microdialysis monitoring.

Stage 2.4.


• Fluid resuscitation: 7% Acetic acid Ringer solution (Veen F) + H2 receptor antagonist (Zantac SOmg/A) + metoclopramide (Prinmperan) 1 A + panthenol (pantol SOO mg x 2).

• Maintenance fluid: actit solution SOO ml + carbazochrome sodium sulfonate (Adona) SO ml + tranexamic acid (Transamin S) 1A+ hemocoagulase (Reptilase-S 1A proteolysis enzyme) (drip).

• Enzyme inhibitor: ulinastatin (Miraclid) 300000 unit/day + maintenance fluid (T4-solution) 400ml (drip). • Proteolysis enzyme: gabexate mesilate (FOY) 1 SOO-2000mg + maintenance fluid (T4-solution) 200ml

(drip). • Antiepileptic phenytoin-phenobarbital (Aleviatin) 2S0mg + saline 20ml (i.v.), flush saline 20ml, Aleviatin

12S mg + saline 20 ml (i.v.). • Adsorbed tetanus toxoid O.S ml (i.m.) + human antitetanus immunoglobulin 2S0 IU (i.m.). • Anesthesia: midazola (20A) + maintenance fluid (T4-soution) 160ml drip 1 ml/h-1 combined drip with

pancuronium bromide (Myoblock) 20A + T4-solution 160ml, and buprenophine hydrochloride (Lepetan) 3-SA + saline 100 ml.

• Heparin calcium (Hepacarin) SOOO U + saline 100 ml drip, S ml/h to prevent complication of Sj02 monitoring.

• Blood transfusion for Hb < 10 mg/dl.


Stage 2.5.


• CPP > 80 mmHg. • ICP < 20 mmHg. • Sj02: 70%-80%. • Trend EEG. • ABER.

Care management of ICP (1) Prevent venous stasis by management of neck position, mediastinal pressure, abdominal hyperten-

sion, full stomach, and bladder pressure. (2) Diagnose the effectiveness of CSF drainage by changes in ICP during 3 min open/close drainage. (3) Continuous CSF drainage. (4) Manage hypercapnia. (S) Replacement of serum albumin to 3.S mg/dl. (6) Head-up position. (7) Management of hyperglycemia and serum electrolytes. (8) Control of blood pressure. (9) Administration of manitol 100 ml/30-60 min.

Stage 2.6.

Monitoring and management of systemic homodynamic changes: CI > 2.2, D021 > SOO, V021 > 12S, 02ER 22-26%, SVRI 1800-2S00, and PAWP > 8-12 mmHg.

• Management of cardiac disturbances: (1) Preload disturbances: administration of crystalloid, colloid, diuretics, and dopamine 1-3Ilg/ml min-1•

(2) Contraction disturbances: administration of dobutrex and/or PDE-III inhibitor. (3) After load disturbances: administration of noradrenalin and/or Ca blocker. (4) Electric imbalance: Na, K, Mg, IP, and Ca.

• Neuronal oxygenation: (1) Pa02/ Fi02> 300-3S0. (2) Manage neck position. (3) Check the correct position of intubation tube. (4) Control mechanical ventilation volume 10-1Sml/kg, PEEP 3-ScmH20, auto-sigh 20-2Sml/kg. (S) Management of red blood cells: Hb > 11 mg/dl, DPG 12-14Ilmol/ml, inorganic phosphate> 3.0 mg/dl.

• Laboratory examinations: blood gas analysis every 2 h, complete blood cell count, serum glucose, serum albumin, IP, Mg, AT-III, D-dimer, a2-PI, SFMC, PF1+2, APC, and platelet aggregation.

• MRSA bacterial analysis. • Gastrointestinal examination and management: gastric juice from N/G tube < 200 ml/day.

Sta

ge

2. A

lgo

rith

m m

anag

emen

t

• S

erum

glu

cose

< 1

60 m

g/dl

: 1.

E

arly

bra

in h

ypot

herm

ia (

33°

-34°

G) i

nduc

tion

with

in 3

h a

fte

r br

ain

dam

age.

Gat

echo

lam

ines

sur

ge-a

ssoc

iate

d hy

perg

lyce

mia

sho

uld

be m

inim

ized

. 2.

R

epla

cem

ent

of

insu

lin.

3.

No

adm

inis

trat

ion

of c

ortis

ol.

4.

Act

ivat

e pr

otei

n sy

nthe

sis

of m

uscl

e by

adm

inis

trat

ion

of a

rgin

ine,

sal

buta

mol

, cl

enbu

tero

l, gl

utam

ine.

5.

In

hibi

t pr

otei

n ca

tabo

lism

: am

urin

one.

6.

R

ehab

ilita

tion

and

kine

tic t

hera

py.

• 5

0 2 >

70

0 m

llmin

and

SS

P>

100

mm

Hg:

1.

F

luid

res

usci

tatio

n, a

dmin

istr

atio

n of

nor

epin

ephr

ine

+ d

opto

rex.

2.

E

last

ic b

anda

ging

of

extr

emiti

es.

3.

Tem

pora

ry i

nser

tion

of a

bdom

inal

bal

loon

cat

hete

r in

to t

he a

bdom

inal

aor

ta.

• H

emog

lobi

n dy

sfun

ctio

n:

1.

Con

trol

of

seru

m p

H>

7.3

. 2.

S

erum

glu

cose

12

0-1

40

mg/

dl.

3.

Ser

um i

norg

anic

pho

spha

te 3

-5 m

g/dl

and

mag

nesi

um 1

.4-1

.Bm

Eq/

1.

4.

Ser

um a

lbu

min

> 3

.5m

g/dl

, vi

tam

in A

50

-10

0m

g/d

l.

• A

T-I

II>

100

%:

repl

acem

ent

of s

erum

alb

umin

. •

Hyp

okal

emia

: co

ntro

l K+

at

3.5

-4.5

mE

q/1

by d

rip o

f K

GI

1 A,

dilu

ted

with

BO

ml

salin

e.

Rep

lace

men

t sp

eed:

40

mllh

for

ser

um K

+ <

2.0

mE

q/1.

20

ml/h

for

ser

um K

+: 1

.2-2

.5 m

Eq/

1.

15 m

l/h f

or s

erum

K+:

2.6

-3.0

mE

q/1.

10

ml/h

for

ser

um K

+: 2

3.1

-3.0

5 m

Eq/

1.

5 m

llh f

or s

erum

K+:

3.6

-34

.0 m

Eq/

1.

VJ 8 ;g ~ ~

0..

?<

" ()

;:l . .....

(S. a '"0

I>' So

~ ~ o """ tIl "' ~. ~ ~ o .....

::r

~ §. I>' ~

~

I>' S ~ ~


Stage 3.1.

Basic care plan:

• Restoration of injured brain tissue. • Maintaining neuronal oxygenation. • Metabolic balance. • Maintaining lipid metabolism. • Management of ICP and brain edema. • Careful management of BBB function. • Control of immune dysfunction. • Maintaining neurohormonal function. • Nutritional consideration. • Prevention of infections.

The major target of leu management at the cooling stage are:

Stage 3.2.

Care order:

• Systolic blood pressure (SBP): control between at 120-160 mmHg by fluid resuscitation. • SBP> 170 mmHg hypertension: drip antihypertensive drug diltiazem hydrochloride (Helvesser). 250 mg.

diluted with 100 ml saline at 2 mllh. Complication of bradycardia (HR < 50 bpm): nicardipine hydrochloride (Perdipin) 2-5 ~g/kg min-1.

• Blood gases: Pa02 > 100 mmHg. Pa02/Fi02 ratio> 350. PaC02 35 mmHg. • Urine volume: more than 0.5 ml/kg h-1.

• Serum glucose: 12Q-140mg/dl by drip of rapid-action insulin (Humarin R): 50U diluted with 100ml saline. * Administration speed: start with 2 ml/h and slow to 1 ml/h after serum glucose becomes lower than

200mg/dl. • Serum potassium: control at 3.S-4.5 mEq/1 by drip of KCI 1 A. diluted with 80 ml saline.

* Replacement speed: 40 ml/h for serum K+ < 2.0 mEq/1. * 20 ml/h for serum K+ 1.2-2.5 mEq/1. * 15ml/h for serum K+ 2.6-3.0mEq/l. * 10ml/h for serum K+ 23.1-3.0SmEq/l. * 5 ml/h for serum K+ 3.6-34.0 mEq/1.


Stage 3.3.

Intervention:

• Ventilator management. • Ventricular drainage. • ICP monitoring. • Sj02 monitoring. • Monitoring of cardiac output and 02ER. • Insert ileum gastric tube. • Kinetic therapy using dyna care bed. • Microdialysis monitoring.

Stage 3.4.


• Fluid resuscitation: 7% Acetic acid Ringer solution (Veen F) + H2 receptor antagonist (Zantac SOmg/A) + metoclopramide (Prinmperan) 1 A + panthenol (pantol SOO mg x 2).

• Maintenance fluid: combination of physiosol-3 SOO ml, Amicaliq SOO ml, and Hicaliq SOO ml (drip). • Administration of vitamins C and E, and ZnCI2 •

• Enzyme inhibitor: ulinastatin (Miraclid) 300000U/day + maintenance fluid (T4-solution) 400ml (drip). • Proteolysis enzyme: gabexate mesilate (FOY) 1 SOO-2000mg + maintenance fluid (T4-solution) 200ml

(drip). • Vitamin kit: vitamin C SOOmg, vitamin B1 SOmg, vitamin B2 20mg, vitamin 6 20mg (i.v.). • Antiepileptic medicine: phenytoin-phenobarbital (Aleviatin) 2S0mg + saline 20ml (i.v.), flush saline

20 ml, Aleviatin 12S mg + saline 20 ml (i.v.). • Antibiotics: immipenem cilastain sodium (Tienam 1-2g/day x 3) > meropenem trihydrate (Meropn,

1.0-2.0g/day x 4) for enterobacteria, gram-negative bacteria, and pseudomonas. • Anesthesia: midazolam (20A) + maintenance fluid (T4-solution) 160ml drip 1 ml/h, combined drip with

pancuronium bromide (Myoblock) 20A + T 4-solution 160 ml, and buprenophine hydrochloride (Lepetan) 3-SA + saline 100 ml.

• Heparin calcium (Hepacarin) SOOO U + saline 100 ml drip, S ml/h to prevent complication of Sj02 monitoring.

• Blood transfusion for Hb > 10 mg/dl.


Stage 3.5.


• Cpp > 80 mmHg. • ICP < 20 mmHg. • Sj02 70%-80%. • Trend EEG. • ABER. • CT. • Brain tissue temperature.

Stage 3.6. - -

Monitoring and management of systemic homodynamic changes: CI > 2.2,0021> 500, V021 > 125, 02ER 22%-26%, SVRI 1800-2500, and PAWP > 8-12 mmHg.


(2) Contraction disturbances: administration of dobutrex and/or POE-III inhibitor. (3) After load disturbances: administration of noradrenalin and/or Ca blocker. (4) Electric imbalance: Na, K, Mg, IP, and Ca.

• Neuronal oxygenation: (1) PaOiFi02 > 300-350. (2) Manage neck position. (3) Check the correct position of intubation tube. (4) Controlled mechanical ventilation volume 10-15 ml/kg, PEEP 3-5cmH20, auto-sigh 20-25ml/kg. (5) Management of red blood cells: Hb> 11 g/dl, OPG 12-14Ilmol/ml, inorganic phosphate >3.0mg/dl.

• Water balance: intake/output each 8 hours. • Laboratory examinations: blood gases analysis every 2 h, complete blood cell count, serum glucose, serum

albumin, IP, Mg, AT-III, D-dimer, a.2-PI, SFMC, PF1 + 2, APC, and platelet aggregation. • MRSA bacterial analysis. • Gastrointestinal examination and care management: gastric juice from N/G tubes <200 ml/day, abdominal X-ray,

nutritional consideration with management of BBB dysfunction (CSF/serum albumin ratio <0.01), and special enteral care management. Cetraxate hydrochloride (Neuer-S), L-glutamine (Glumin-S), Antibiotic-resistent lactic acid bacteria (Biofermin-R), potassium permanganate, and Oaiken Tyutou are enteral management drugs.

Sta

ge

3. A

lgo

rith

m m

anag

emen

t

1.

Inte

rmit

ten

t h

ypo

the

rmia

: pr

olon

ged

brai

n hy

poth

erm

ia,

belo

w 3

2°

-33

°C

, pro

duce

s a

redu

ctio

n of

pitu

itary

hor

mon

es.

Def

icie

ncy

of g

row

th h

orm

one

and

thyr

oid

horm

ones

cau

ses

an u

navo

idab

le d

eple

tion

of i

mm

une

func

tion.

To

prev

ent

this

com

plic

atio

n, i

nter

mitt

ent

cont

rol

of b

rain

tis

sue

tem

pera

tu

re b

etw

een

32°

C a

nd 3

4°C

is a

ver

y us

eful

man

agem

ent t

echn

ique

. T

he t

empo

rary

ele

vatio

n of

bra

in t

issu

e te

mpe

ratu

re is

rec

omm

ende

d at

18

00

-22

00

ho

urs

beca

use

phys

iolo

gica

l gr

owth

hor

mon

e is

nat

ural

ly r

elea

sed

at t

his

time.

The

det

aile

d te

chni

ques

are

des

crib

ed p

revi

ousl

y in

thi

s bo

ok.

2.

Bra

in e

de

ma

an

d c

on

tro

l o

f IC

P <

15

mm

Hg

: IC

P e

leva

tion

to m

ore

than

20

mm

Hg

prod

uces

ven

ous

stas

is a

nd d

istu

rban

ces

of m

icro

circ

ulat

ion.

To

prev

ent

mic

roci

rcul

atio

n, C

SF

dra

inag

e, h

ead-

up p

ositi

on,

redu

ctio

n of

abd

omin

al p

ress

ure

and

med

iast

inal

pre

ssur

e, p

reve

ntio

n of

hyp

o-al

bum

inem

ia,

adm

inis

trat

ion

of h

yper

-osm

otic

sol

utio

n, m

anito

l, an

d re

duct

ion

of C

SF

pro

duct

ion

by a

ceta

zola

mid

e (D

iam

ox)

are

pres

crib

ed m

anag

emen

t. 3.

A

T-I

II>

100

%:

perip

hera

l va

scul

ar s

tasi

s is

one

of t

he c

ompl

icat

ions

of

the

cool

ing

stag

e of

bra

in h

ypot

herm

ia.

Pro

long

ed b

ed r

est,

perip

hera

l va

scul

ar

cont

ract

ion,

sub

cuta

neou

s ed

ema

caus

ed b

y th

e co

mpl

icat

ion

of h

ypo-

albu

min

emia

, co

mpl

icat

ion

of i

nfec

tion,

and

con

sum

ptio

n on

of

AT

-III

by s

ever

e br

ain

dam

age

are

caus

es o

f re

duct

ed o

f AT-

III.

Low

er t

han

80

%-9

0%

of

AT-

III i

s cr

itica

l an

d pr

omot

es t

he s

yste

mic

dis

turb

ance

of

mic

roci

rcul

atio

n an

d de

velo

pmen

t of i

nfla

mm

atio

n of

vas

cula

r in

timae

. O

ur c

linic

al s

tudi

es s

ugge

st th

e m

anag

emen

t of A

T-III

affe

cts

to p

rogn

osis

and

suc

cess

of b

rain

hyp

othe

rm

ia t

reat

men

t. 4.

S

eru

m a

lbu

min

>3.

5 m

g/d

l: p

rolo

nged

hyp

othe

rmia

pro

mot

er s

ynth

esis

of

prot

ein

and

albu

min

. In

crea

sing

cyt

okin

es p

rodu

ces

hypo

-alb

umin

emia

. In

se

vere

ly b

rain

-inju

red

patie

nts,

rap

id d

evel

opm

ent

of h

ypo-

albu

min

emia

is a

big

clin

ical

iss

ue.

Pro

gres

sion

of

brai

n ed

ema,

ine

ffect

ive

man

itol

hype

ros

mot

ic d

iure

tics

for

brai

n ed

ema,

com

plic

atio

n of

pul

mon

ary

edem

a, i

ntes

tinal

muc

ous

edem

a pa

ncre

atic

duc

t obs

truc

tion

caus

ed b

y in

test

inal

wal

l ede

ma,

im

mun

e dy

sfun

ctio

n, b

acte

rial

tran

sloc

atio

n, u

nsta

ble

phar

mac

olog

ical

fun

ctio

n of

pro

tein

-bin

ding

dru

gs,

incr

ease

d fr

ee b

acte

ria a

nd e

ase

of i

nfec

tion

are

maj

or c

ompl

icat

ions

of

hypo

-alb

umin

emia

. T

here

fore

, re

plac

emen

t of

alb

umin

and

nut

ritio

nal c

onsi

dera

tion

for

hypo

-alb

umin

emia

are

impo

rtan

t m

an

agem

ent

stra

tegi

es d

urin

g th

e co

olin

g st

age

of b

rain

hyp

othe

rmia

tre

atm

ent.

5.

Imm

un

e d

ysfu

nct

ion

: re

duce

d gr

owth

hor

mon

e le

vels

and

ene

rgy

cris

is in

lym

phoc

ytes

are

maj

or c

ause

s of

imm

une

dysf

unct

ion

durin

g br

ain

hypo

ther

m

ia t

reat

men

t. T

he r

educ

tion

of g

row

th h

orm

one

is u

navo

idab

le w

ith p

rolo

nged

mod

erat

e br

ain

hypo

ther

mia

bec

ause

the

tem

pera

ture

of

the

pitu

itary

gl

and

is a

lso

low

ered

. G

luta

min

e is

the

ene

rgy

sour

ce f

or ly

mph

ocyt

es a

nd i

s pr

oduc

ed in

lun

g tis

sue

and

skel

etal

mus

cles

. T

his

glut

amin

e is

exp

ende

d by

lym

phoc

ytes

in

the

inte

stin

al d

iges

tive

orga

ns.

The

refo

re,

mus

cle

hypo

met

abol

ism

, pu

lmon

ary

infe

ctio

n, a

nd m

ucou

s ed

ema

in t

he d

iges

tive

orga

n ca

used

by

hypo

-alb

umin

emia

als

o pr

oduc

e im

mun

e dy

sfun

ctio

n. A

dmin

istr

atio

n of

arg

inin

e, s

albu

tam

ol,

and

grow

th h

orm

one

are

effe

ctiv

e in

mai

ntai

nin

g im

mun

e fu

nctio

n be

caus

e of

stim

ulat

ion

of p

rote

in s

ynth

esis

in

skel

etal

mus

cles

and

pro

mot

ion

of t

he l

ipid

met

abol

ism

whi

ch i

s th

e m

ain

met

abo

lism

und

er h

ypot

herm

ia.

6.

Pre

ven

tio

n o

f in

fect

ion

: co

mpl

icat

ion

with

sev

ere

infe

ctio

n du

ring

the

cool

ing

stag

e ca

uses

the

fai

lure

of

brai

n hy

poth

erm

ia t

reat

men

t. In

crea

sed

seru

m

proi

nfla

mm

ator

y cy

toki

nes

can

perm

eate

the

dam

aged

BB

B a

nd p

rodu

ce c

ytok

ine

ence

phal

itis

with

unc

ontr

olla

ble

incr

ease

s of

neu

roto

xic

glut

amat

e in

in

jure

d br

ain

tissu

e. T

here

fore

, as

man

agem

ent

of in

fect

ion

durin

g br

ain

hypo

ther

mia

trea

tmen

t, th

e ki

lling

of

bact

eria

, ac

tivat

ion

of im

mun

e fu

nctio

n, t

he

man

agem

ent

of B

BB

(C

SF

/ser

um a

lbum

in r

atio

<0.

01),

man

agem

ent

of s

erum

alb

umin

(>3

.5 g

/dl),

no

activ

atio

n of

vas

opre

ssin

rel

ease

by

neur

al c

ontr

ol

of t

he f

eedb

ack

mec

hani

sm t

o hy

perg

lyce

mia

, m

aint

enan

ce o

f pr

otei

n sy

nthe

sis

in s

kele

tal

mus

cles

, an

d ad

min

istr

atio

n of

bac

teria

-sen

sitiv

e no

n-pr

otei

nbi

ndin

g an

tibio

tics

are

indi

cate

d. T

he i

nter

mitt

ent

cont

rol

of b

rain

tis

sue

tem

pera

ture

at

32

°-3

3°

C, a

dmin

istr

atio

n of

arg

inin

e, a

nd r

ehab

ilita

tion

of s

kele

ta

l m

uscl

es a

re a

lso

effe

ctiv

e to

inc

reas

e th

e im

mun

e fu

nctio

n. T

he c

hoic

e of

sys

tem

ic a

dmin

istr

atio

n of

ant

ibio

tics

and

dige

stiv

e de

cont

amin

atio

n an

tibio

tics

ther

apy

was

des

crib

ed p

revi

ousl

y in

thi

s bo

ok.

7.

Act

iva

tio

n o

f lip

id m

eta

bo

lism

: br

ain

hypo

ther

mia

bel

ow 3

4°C

pro

duce

s m

etab

olic

shi

ft fr

om g

luco

se to

lipi

d m

etab

olis

m.

The

lipi

d m

etab

olis

m r

equi

res

vita

min

A a

nd a

dequ

ate

grow

th h

orm

one

for

ener

gy m

etab

olis

m w

ithou

t la

ctat

e pr

oduc

tion.

Exc

essi

ve r

epla

cem

ent

of g

row

th h

orm

one

prod

uces

hyp

er

glyc

emia

. T

here

fore

, ca

refu

l m

onito

ring

of s

erum

glu

cose

is

impo

rtan

t fo

r re

plac

emen

t th

erap

y of

gro

wth

hor

mon

e an

d ar

gini

ne.

w ss: ;J>

'0

'0

(1l ;:;

0.. ?<' ~ (S

. a '"0

Il:l So

~

~ o ....,

to .., Il:

l S· ::r: ~ o So

(1l S ;. ~

(1l

Il:l 8' (1l g


Stage 4.1.

Basic care plan:

Rewarning can occur after exact diagnosis of some form of recovery. The recording of a 9 wave on the background of the 8 wave in trend EEG, no ICP elevation, Sj02 control at 60%-70%, and no brain swelling on CT scan are basic signs of neuronal recovery. To succeed in rewarming from brain hypothermia treatment, various preconditioning managements are needed.

Stage 4.2.

Care order:

Rewarming from brain hypothermia, especially prolonged treatment below 34°C, produces various physiological changes such as metabolic shift from lipid to glucose, vascular engorgement, increased of metabolic activity, activated cytokine production, increase in ·NO radicals, increased serum cytokines, uncoupling of bloodflow and metabolism in major organs, and oxygen demand in the brain tissue. Before rewarming, preconditioning management is recommended for adaptation or prevention of negative effects to the brain by these physiological changes. The major targets for preconditioning care are:

• No severe infection. • Lymphocytes> 1500/mm3. • T-H (CD4) lymph >55%. • Serum glucose 120-140 mg/dl. • Prealbumin >20 mg/dl. • Serum albumin >3.5 mg/dl. • Vitamin A >50 mg/dl. • Hb> 12mg/dl. • 02ER 23%-25%. • AT-III> 100%. • Gastric pHi> 7.35.

The success of management ensures no trouble during rewarming.


Stage 4.3.

Intervention:

• EEG (recovery from () wave to 8 wave or recording of a wave ). • ABR. • Brain CT (no signs of brain swelling or severe brain edema). • ICP «20mmHg). • CPP (>70-80 mmHg). • Prevention of systemic infection by combined administration of antibiotics:

(1) Digestive decontamination: control of clostridium enteritis and MRSA by enteral administration of levofloxacin (Cravit, 200 mg) and Amphotericin B, 100-300 mg.

(2) Combined with vancomycin for (2-3g/day x 4-6 times i.v. drip) is useful prophylactic management for rewarming stage infection.

Stage 4.4.


• Maintenance fluid: combination of physiosol-3 500 ml, amicaliq 500 ml, 7% acetic acid Ringer solution (Veen F) and hicaliq 500ml (drip). Calorie increases with monitoring of serum glucose.

• Administration of vitamins C and E, and ZnCI2. • Enzyme inhibitor: ulinastatin (Miraclid) 300000U/day+maintenance fluid (T4-solution) 400ml (drip). • Proteolysis enzyme: gabexate mesilate (FOY) 1500-2000 mg + maintenance fluid (T 4-solution)

200ml (drip). • Antiepileptic phenytoin-phenobarbital, Aleviatin 125mg + saline 20ml (i.v.), prepare the flush saline

20ml. • Antibiotics: arbekacin sulfate (Habekacin, 150-200 mg/day x 2) to prevent pseudomonal aerginosa and

MRSA infection, + cefozopran hydrochloride (Firstcin 1-2g/day x 2) for Tienam resistant Acinetobacter and xantomona + fluconazole (Diflucan 100-200 mg/day x 1) for Candida with evidence of B-D-Glucanpositive reactions).

• Anesthesia: midazola (20A) + maintenance fluid (T4-soution) 160ml drip 1 ml/h, combined drip with pancuronium bromide (Myoblock) 20A + T 4-solution 160 ml, and buprenophine hydrochloride (Lepetan) 3-5A + saline 100 ml.

• Heparin calcium (Hepacarin) 5000 U + saline 100 ml drip, 5 ml/h to prevent complication of Sj02 monitoring.

• Blood transfusion for Hb < 10 mg/dl.


Stage 4.5.


• CPP > 80 mmHg. • ICP > 20 mmHg. • Sj02 70%-80%. • Trend EEG (recovery from 8 wave to e wave or recording of a wave). • ABER. • Brain CT (no signs of brain swelling, severe brain edema or ICP elevation).

Stage 4.6.

Monitoring and management of systemic homodynamic changes: CI > 2.2,0021> SOO, \/021> 12S, 02ER 22%-26%, SVRI 1800-2S00, and PAWP > 8-12mmHg.


(2) Contraction disturbances: administration of dobutrex and/or PDE·III inhibitor. (3) After load disturbances: administration of noradrenalin and/or Ca blocker. (4) Electric imbalance: Na, K, Mg, IP, and Ca.

• Neuronal oxygenation: (1) Pa02/Fi02> 300-3S0. (2) Manage neck position. (3) Check the correct position of intubation tube. (4) Controlled mechanical ventilation volume 10-1Sml/kg, PEEP 3-ScmH20, auto-sigh 20-2Sml/kg. (S) Management of red blood cells: Hb > 11 mg/dl, DPG 12-14Ilmol/ml, inorganic phosphate >3.0mg/dl.

• Water balance: intake/output every 8 hours. • Laboratory examinations: PaC02 32-36mmHg, serum glucose 120-1S0mmHg, serum albumin

>3.Smg/dl, IP > 3mg/dl, AT-III> 120%, D-dimer. • Gastrointestinal examination and management:

(1) Gastric juice from N/G tubes <200 ml/day. (2) Abdominal X-ray. (3) Nutritional consideration for management of BBB dysfunction (CSF/serum albumin ratio <0.01). (4) Special enteral care management.

* Cetraxate hydrochloride (Neuer-S), L-glutamine (Glumin-S), antibiotic-resistant lactic acid bacteria (Biofermin-R), potassium permanganate, and Daiken Tyutou are enteral management drugs.

* The management of digastrics decontamination with nonabsorbable and hypothermia-active antibiotics levofloxacin (Cravit, 200 mg) and amphotericin B, 100-300 mg, combined with intravenous drip administration of Vancomycin (2-3g/day x 4-6 times) are indicated for prevention of systemic infections.

Sta

ge

4.

Alg

ori

thm

ma

na

ge

me

nt

1.

Evi

de

nce

of

ne

uro

na

l re

cove

ry:

the

big

issu

e at

rew

arm

ing

is r

epro

gres

sion

of

brai

n in

jury

mec

hani

sm t

hat

was

sto

pped

at

the

cool

ing

stag

e. W

ithou

t ev

iden

ce o

f ne

uron

al r

ecov

ery

or a

t le

ast s

igns

of

reco

very

, re

war

min

g m

akes

the

cond

ition

muc

h w

orse

. If

neur

onal

rec

ov

ery

was

not

dia

gnos

ed b

y m

onito

ring

of I

CP

, S

j02,

EE

G,

and

CS

F b

ioch

emic

al c

hang

es,

the

cool

ing

stag

e sh

ould

be

exte

nded

for

a f

ew

mor

e da

ys.

Man

agem

ent

is s

ame

as S

tand

ard

Man

agem

ent,

Sta

ge 4

.1.

Bas

ic C

are

Pla

n, S

tage

4.2

. C

are

Ord

er,

Sta

ge 4

.3.

Inte

rven

tio

n, S

tage

4.4

. In

trav

enou

s M

edic

atio

n, S

tage

4.5

. B

rain

Mon

itorin

g, S

tage

4.6

. M

onito

ring

and

Man

agem

ent

of S

yste

mic

Hom

odyn

amic

C

hang

es,

and

Alg

orith

m M

anag

emen

t. N

o si

gns

of b

rain

ede

ma

or

othe

r co

mpl

icat

ions

on

the

CT

exa

min

atio

n ar

e al

so u

sefu

l to

dia

gno

se n

euro

nal

reco

very

. 2.

N

o s

eve

re i

nfe

ctio

n a

nd

CS

F/s

eru

m A

lbu

min

<0.

01:

the

elev

atio

n of

bod

y te

mpe

ratu

re b

y re

war

min

g st

imul

ates

the

act

ivity

of

seru

m

cyto

kine

s. I

ncre

ased

ser

um c

ytok

ines

can

eas

ily p

erm

eate

the

dam

aged

BB

B.

Thi

s se

rious

com

plic

atio

n ca

uses

the

fai

lure

of

the

brai

n hy

poth

erm

ia t

reat

men

t at

the

rew

arm

ing

stag

e. T

here

fore

, m

anag

emen

t of

sev

ere

pulm

onar

y in

fect

ion

and

man

agem

ent

of B

BB

dys

fu

nctio

n (C

SF

/ser

um a

lbum

in r

atio

low

er t

han

0.01

) m

ust

be a

chie

ved

befo

re r

ewar

min

g. T

he a

ctua

l m

anag

emen

t m

etho

d is

des

crib

ed

prev

ious

ly in

thi

s bo

ok.

3.

Se

rum

glu

cose

12

0-1

40

mg/

dl:

adm

inis

trat

ion

of i

nsul

in w

ith c

ontr

ol o

f se

rum

pho

spha

te a

nd m

agne

sium

, 7%

ace

tate

Rin

ger

solu

tion,

co

ntra

indi

cate

d st

eroi

d, a

ctiv

ate

resp

irato

ry m

uscl

e m

etab

olis

m b

y sa

lbut

amol

. 4.

E

nte

ral

nu

trit

ion

: th

e m

anag

emen

t of

nut

ritio

n at

the

rew

arm

ing

stag

e re

quire

s th

e re

plac

emen

t of

an

ener

gy s

ourc

e of

cal

orie

s, f

eed

to i

mm

une

cells

, st

abili

zatio

n of

the

int

estin

al d

iges

tive

orga

n, a

nd m

aint

enan

ce o

f nu

triti

onal

con

ditio

ns.

The

man

agem

ent

of B

BB

dys

fu

nctio

n is

als

o im

port

ant

beca

use

neur

otox

ic g

luta

mat

e in

crea

ses

abou

t tw

o to

thr

ee t

imes

with

ent

eral

and

par

ente

ral

amin

o ac

id n

utri

tion.

In

wel

l-or

gani

zed

BB

B w

ith C

SF

/ser

um a

lbum

in r

atio

low

er th

an 0

.01,

mic

rodi

alys

is s

tudi

es p

rovi

ded

no e

vide

nce

of s

erum

glu

tam

ate

pass

ing

into

the

bra

in t

issu

e an

d no

evi

denc

e of

wor

seni

ng b

rain

ede

ma.

P

relim

inar

y m

anag

emen

t of

BB

B d

ysfu

nctio

n w

ith r

epla

cem

ent

of s

erum

alb

umin

to

high

er th

an 3

.5 g

/dl,

anti-

infla

mm

ator

y m

edic

ine

for

the

vasc

ula

r w

all

such

as

AT-

III a

nd p

rote

in C

, an

d ra

dica

l sc

aven

ger

such

as

Rad

icut

are

use

ful

to a

void

nut

ritio

nal

com

plic

atio

ns a

t th

e re

war

min

g st

age.

The

rep

lace

men

t of

ser

um a

lbum

in i

s ve

ry e

ffec

tive

for

the

cont

rol

of i

ntes

tinal

muc

ous

mem

bran

e ed

ema

and

pre

vent

ion

of d

iarr

hea

caus

ed b

y en

tera

l nu

triti

on.

Pre

limin

ary

feed

ing

(with

glu

tam

ine

and

argi

nine

), c

orre

ct s

erum

ele

ctro

lyte

s, c

ontr

ol o

f th

e os

mot

ic g

ap (

seru

m O

sm -

2 (s

tool

Na

+ K

) >

100

mO

smkl

kg)

and

man

agem

ent

of m

esen

teri

c is

chem

ia a

re a

lso

usef

ul b

efor

e fe

edin

g m

anag

emen

t. T

wo

actu

al e

nter

al n

utrit

ion

cour

ses

are

prep

ared

. O

ne u

ses

salin

e im

mun

e nu

triti

on (

glut

amin

e +

arg

inin

e +

yea

st R

NA

) w

ith a

dmin

is

trat

ion

of h

oney

yog

urt,

and

cont

rol

of B

BB

fun

ctio

n at

CS

F/s

erum

alb

umin

rat

io l

ower

than

0.0

1. T

he o

ther

is t

wo-

step

ent

eral

nut

ritio

n w

ith C

SF

/ser

um a

lbum

in 0

.01

-0.0

2.

Firs

t st

ep:

salin

e 50

ml

to m

ax 1

50 m

l/4 h

, an

d re

mov

e re

tent

ion

fluid

rep

eat

for

3-4

day

s. S

econ

d st

age:

adm

inis

trat

ion

of h

oney

yog

urt

(50

ml

to m

ax 1

50 m

ll4 h

). T

he d

etai

l te

chni

ques

are

des

crib

ed e

arlie

r in

thi

s bo

ok.

The

com

bina

tio

n of

ent

eral

nut

ritio

n w

ith h

oney

yog

urt

and

argi

nine

is v

ery

effe

ctiv

e fo

r st

imul

atio

n of

lip

id m

etab

olis

m w

ithou

t pr

oduc

tion

of l

acta

te.

V)

o 00

~

'"d (1) ::l

0..

?<" Q

.... ri· e:..

'"d

~ ~ ~ '-<

: a to ... ~ Er :r: '-<

: '"

d o .... ::r

(1) §. ~ ~

(1) ~ 8' (1

) a


Stage 5.1.

Basic care plan:

• Rewarming from mild brain hypothermia can be performed with increases of brain tissue temperature of 0.1 DC/h.

• However, rewarming from 32D-33DC requires an adaptation time for uncoupling between metabolic changes and blood flow at 34D-35DC for about 1-2 days.

Stage 5.2.

Care order:

• Systolic blood pressure (SBP): control between at 120-160 mmHg by fluid resuscitation. • SBP> 170mmHg hypertension: drip the antihypertensive drug, diltiazem hydrochloride (Helvesser),

250 mg, diluted with 100 ml saline at 2 ml/h. Complication of bradycardia (HR < 50 bpm): nicardipine hydrochloride (Perdipin) 2-5llg/kg min-'.

• Blood gases: Pa02 > 100 mmHg, PaOiFi02 ratio >350, PaC02 35 mmHg. • Urine volume: more than 0.5 ml/kg h-'. • Serum glucose: 120-140 mg/dl by drip of rapid-action insulin (Humarin R) 50 U diluted with 100 ml saline.

* Administration speed: start at 2 mllh and slow to 1 ml/h after serum glucose becomes lower than 200mg/dl.

• Serum potassium: control at 3.5-4.5 mEq/1 by drip of KCI 1 A, diluted with 80 ml saline. * Replacement speed: 40 ml/h for serum K+ < 2.0 mEq/1. * 20 ml/h for serum K+ 1.2-2.5 mEq/1. * 15 ml/h for serum K+ 2.6-3.0 mEq/1. * 10ml/h for serum K+ 23.1-3.05mEq/l. * 5 ml/h for serum K+ 3.6-34.0 mEq/1.


Stage 5.3.

Intervention:

• Change ileus tube to ED tube. • Digestive decontamination for control of clostridium enteritis and MRSA by enteral

administration of levofloxacin (Cravit, 200 mg) and amphotericin B (100-300 mg). • Combine with vancomycin (2-3g/day x 4-6 times i.v. drip) is useful prophylactic man

agement of rewarming stage infections.

Stage 5.4.


• Maintenance fluid: hicaliq-1 700 ml + amizet XS 300 ml + 10% NaCI 2A + zantac 20A + panrol 500 mg x 2 (drip).

• Administration of vitamins S, C, and E, and ZnCI2. • Proteolysis enzyme: gabexate mesilate (FOY) 1500-2000 mg + maintenance fluid (Solita T 4-solution)

200ml (drip). • Antiepileptic phenytoin-phenobarbital, Aleviatin 125 mg + saline 20 ml (i.v.) , prepare the flush saline

20ml. • Change the antibiotics: arbekacin sulfate (Habekacin, 150-200 mg/day x 2) to prevent pseudomonal

aerginosa and MRSA infection, + cefozopran hydrochloride (Firstcin 1-2g/day x 2) for Tienam-resistant Acinetobacter and xantomona + fluconazole (Diflucan 100-200 mg/day x 1) for Candida with evidence of ~-D-glucan positive reactions) .

• Anesthesia: midazolam (20A) + maintenance fluid (T 4-soution) 160 ml drip 1 ml/h, combined drip with pancuronium bromide (Myoblock) 20A + T4-solution 160ml, and buprenophine hydrochloride (Lepetan) 3-5A + saline 100 ml.

• Heparin calcium (Hepacarin) 5000 U + saline 100 ml drip, 5 ml/h for prevent to complication Sj02 monitoring.


Stage 5.5.

Brain monitoring and managment:

• ICP < 25 mmHg. • Sj0 2 60%-75%. • CPP > 80 mmHg. • ABER. • CT.

Stage 5.6. - -

Monitoring and management of systemic homodynamic changes: CI > 2.2,0021> 500, V021 > 125, 02ER 22%-26%, SVRI 1800-2500, and PAWP> 8-12mmHg.

• Management of cardiac disturbances: (1) Preload disturbances: administration of crystalloid, colloid, diuretics, and dopamine 1-3Ilg/ml min-1.

(2) Contraction disturbances: administration of dobutrex and/or POE-III inhibitor. (3) After load disturbances: administration of noradrenalin and/or Ca blocker. (4) Electric imbalance: Na, K, Mg, IP, and Ca.

• Neuronal oxygenation: (1) PaOiFi02 > 300-350. (2) Manage neck position. (3) Check correct intubation tube position. (4) Controlled mechanical ventilation volume 10-15ml/kg, PEEP 3-5cmH20, auto-sigh 20-25ml/kg. (5) Management of red blood cells: Hb> 11 mg/dl, OPG 12-14IlmollmL, inorganic phosphate >3.0mg/dl.

• Water balance: intake/output every 8 hours (two times/day). • Laboratory examinations: PaC02: 32-36mmHg, serum glucose 120-150mg/dl, serum albumin >3.5mg/dl,

IP > 3mg/dl, AT-III> 120%, O-dimer, platelet. • Gastro-intestinal examination and care management:

(1) Gastric juice from N/G tube abdominal X-ray, nutritional consideration for management of BBB dysfunction (CSF/serum albumin ratio <0.01).

(2) Special enteric care management. Cetraxate hydrochloride (Neuer-S), L-glutamine (Glumin-S), antibioticresistant lactic acid bacteria (Biofermin-R), potassium permanganate, and Oaiken Tyutou are enteric management drugs.

(3) The management of digastrics decontamination with nonabsorbable and hypothermia-active antibiotics (combination of levofloxacin (Cravit, 200 mg) and amphotericin B, 100-300 mg).

(4) Combined intravenous drip of vancomycin (2-3g/day x 4-6 times) and administration of enteric nutrition are indicated to prevent systemic infections.

Sta

ge

5. A

lgo

rith

m m

anag

emen

t

• T

he

con

tro

l o

f b

rain

tis

sue

tem

per

atu

re:

rew

arm

ing

from

sho

rt-d

urat

ion

brai

n hy

poth

erm

ia is

not

diff

icul

t, ho

wev

er,

rew

arm

ing

from

pro

long

ed b

rain

hyp

othe

rmia

pro

duce

s m

any

nega

tive

effe

cts

on t

he i

njur

ed b

rain

tis

sue.

Ste

p w

ise

rew

arm

ing

to 3

4°C

and

the

n an

ada

ptat

ion

time

of 1

-2 d

ays

is v

ery

succ

essf

ul f

or r

ewar

min

g fr

om p

rolo

nged

mod

er

ate

brai

n hy

poth

erm

ia tr

eatm

ent.

Afte

r th

at,

the

cool

ing

blan

ket

is r

emov

e fr

om t

he b

ody

piec

e by

pie

ce o

ver

1-2

da

ys.

Thi

s ca

refu

l re

war

min

g te

chni

que

for

prol

onge

d br

ain

hypo

ther

mia

tre

atm

ent

is o

ne o

f th

e ke

y po

ints

for

su

cces

s of

bra

in h

ypot

herm

ia t

reat

men

t. •

Pre

ven

tio

n o

f h

yper

gly

cem

ia:

adm

inis

trat

ion

of i

nsul

in b

y dr

ip i

s us

eful

for

the

con

trol

of

hype

rgly

cem

ia.

In t

his

stag

e, g

row

th h

orm

one

to i

ncre

ase

the

imm

une

activ

ity is

not

rec

omm

ende

d, b

ecau

se t

his

mak

es c

ontr

ol o

f hy

per

glyc

emia

diff

icul

t be

caus

e of

incr

easi

ng s

erum

glu

cose

. M

icro

dial

ysis

stu

dies

sug

gest

tha

t co

ntro

l of

ser

um g

luco

se

at 1

30

-15

0 m

g/dl

is

effe

ctiv

e.

• O

xyg

en m

etab

oli

sm:

the

oxyg

en d

eman

d in

crea

ses

durin

g th

e re

war

min

g st

age.

The

con

trol

of

oxyg

en d

eliv

ery

over

700

ml/m

in,

Pa

OiF

i02

> 3

50,

and

02E

R 2

3%

-35

% a

re f

unda

men

tal.

To m

aint

ain

hem

oglo

bin

func

tion,

the

co

ntro

l of

Pa

C0

2 3

2-3

6m

mH

g,

seru

m p

H 7

.3-7

.4,

seru

m p

hosp

hate

>3m

g/dl

, an

d se

rum

Mg+

> 1

.3m

mol

/dl

are

also

im

port

ant.

The

maj

or p

itfal

l of

oxy

gen

man

agem

ent

at t

he r

ewar

min

g st

age

is t

he e

arly

man

agem

ent

of s

pon

tane

ous

brea

thin

g w

ithou

t su

ffici

ent

oxyg

en d

eliv

ery

and

cont

rol

of h

emog

lobi

n dy

sfun

ctio

n. S

pont

aneo

us b

reat

hin

g is

effe

ctiv

e to

avo

id p

ulm

onar

y at

elec

tasi

s, h

owev

er,

oxyg

en d

eman

d al

so i

ncre

ases

. S

pont

aneo

us b

reat

hing

ca

n ca

use

brai

n hy

poxi

a w

ith p

oor

oxyg

en d

eliv

ery

and

hem

oglo

bin

DP

G r

educ

tion.

Thi

s is

the

las

t pi

tfall

of u

nsuc

ce

ssfu

l br

ain

hypo

ther

mia

tre

atm

ent.

Ven

tilat

or b

reat

hing

m

anag

emen

t sh

ould

be

us

ed

until

the

end

sta

ge o

f re

war

min

g un

der

anes

thes

ia,

anal

gesi

a, a

nd m

uscl

e re

laxa

tion.

•

Infe

ctio

us

con

tro

l: t

he w

orse

ning

of

infe

ctio

n at

the

rew

arm

ing

stag

e is

rar

e w

ith g

ood

man

agem

ent

of p

reco

ndi

tioni

ng.

The

man

agem

ent

tech

niqu

e to

con

trol

inf

ectio

n is

ver

y di

ffere

nt a

s pr

evio

usly

des

crib

ed.

Infe

ctio

us c

ontr

ol

durin

g th

e co

olin

g st

age,

alg

orith

m m

anag

emen

t m

etho

d fo

r in

fect

ion

cont

rol,

and

man

agem

ent

at t

he p

reco

ndi

tioni

ng s

tage

hav

e re

duce

d th

e co

mpl

icat

ion

of p

neum

onia

to l

ess

than

10%

in o

ur IC

U.

The

com

plic

atio

n of

sev

ere

pulm

onar

y in

fect

ion

with

se

vere

B

BB

da

mag

e (C

SF

/ser

um

albu

min

>

0.0

1-0

.02

) pr

oduc

es

chem

ical

cy

toki

ne

ence

phal

itis.

The

com

plic

atio

n of

sev

ere

infe

ctio

n du

ring

brai

n hy

poth

erm

ia in

dica

tes

failu

re o

f the

trea

tmen

t. C

aref

ul

man

agem

ent

of i

nfec

tion

durin

g br

ain

hypo

ther

mia

tre

atm

ent

is i

mpo

rtan

t.

w

......

N ~

"0

(D

:::s

0..

?<" n a· o· e:..

"0

." s :E ~ o ....,

tc

"1

." s· ~ o s- (D S s;.

::;l

(D

." §' (D g


Stage 6.1.

Basic care plan:

The basic treatments for the restoration of vegetative patients after brain hypothermia treatment are:

• The management techniques to prevent the release of dopamine at the acute stage was discussed in the algorithm care management section and earlier in this book.

• The major restoration therapy for vegetation is the management of the dopamine A 10 nervous system. The various neuronal injury patterns in the dopamine A 10 nervous system can be considered in vegetate patients: (1) No functioning of the dopamine A 10 nervous system, however, remaining dopamine very resistant

to the management of CBF and brain metabolism. (2) Synaptic confusion in the dopamine A 10 nervous system is caused by retention of neurotransmit

ters in interstitial space. (3) Reduced metabolic substrates for production of synaptic dopamine. (4) Feeble dopamine synapses.

• The replacement of metabolic substrates of dopamine neurotransmitters could be through: (1) Pharmacological replacement. (2) Electrophysiological stimulation of the dopamine A 10 nervous system. (3) Increasing activity of the dopamine A 10 nervous system by hormonal therapy, and monitoring of

the dopamine A 10 nervous system responsiveness.

Stage 6.2.

Care order:

• Systolic blood pressure (SBP): control between 120-160 mmHg by fluid resuscitation. • Blood gases: Pa02 > 100 mmHg, PaOiFi02 ratio >350, PaC02 35 mmHg. • Urine volume: more than 0.5 mllkg h-1 .

• Serum glucose: 120-140 mg/dl by drip of rapid-action insulin (Humarin R): 50 U diluted with 100 ml saline.

• Serum potassium: control at 3.5-4.5 mEq/1. • Serum magnesium: control> 1.0 mmol/I. • Serum inorganic phosphate: 2.5-4.5 mg/dl. • Prolactin: male 2-18ng/ml, female 2-30ng/ml. • T 4-throxin: free 0.8-1.8 ng/dl, total 4.5-12/lg/dl. • Estron: male 29-81 pg/mL, female 40-150pg/ml.


Stage 6.3.

Intervention:

• Electrical median nerve stimulation for 3 weeks: 10-20mA, 20s on, 30s off, 30 pulse/s, duration time 300 ms.

• Emotional stimulation: music therapy and talking.

Stage 6.4.

Medication:

• Intracerebral dopamine replacement therapy: Levodopa (300-400 mg/day) Amantadine (100-200 mg/day) Parodel (10-15 mg/day).

• Estrogen (Estraderm TTS patch 2 mg/day) patch therapy. • Antiepileptic therapy. • Replacement of vitamin B.


Stage 6.5.


• CSF neurotransmitter analysis: dopamine, norepinephrine, and serotonin. • Responsiveness of dopamine A 10 nervous system: increasing of CSF dopamine/CSF

prolactin ratio after treatment. • EEG. • CT. • MRI. • Xe-CBF. • Somatosensory evoked potential (extend N20 position or disappearance of N20). • Visual evoked potential (extend the P300 300 msec positive wave).

Stage 6.6.

Monitoring and management of systemic homodynamic changes:

• SBP > 100 mmHg, 02ER 22%-26%. • Management of cardiac function. • Electric imbalance: Na, K, Mg, IP, and Ca. • Neuronal oxygenation:

PaOiFi02 > 300-350 Hb> 11 mg/dl DPG 12-14 ~mol/ml inorganic Phosphate >3.0 mg/dl.

• Water balance: Ht < 40. • Laboratory examinations:

Serum glucose 120-150 mmHg Serum albumin >3.5 mg/dl AT-III> 120%.

Sta

ge

6.

Alg

ori

thm

ma

na

ge

me

nt

• D

op

am

ine

re

pla

cem

en

t th

era

py:

do

pam

ine

repl

acem

ent

ther

apy

prov

ider

su

ppor

t fo

r th

e no

n-fu

nctio

ning

do

pam

ine

A 1

0 ne

rvou

s sy

stem

. T

he r

espo

nsiv

enes

s of

the

dop

amin

e A

10

nerv

ous

syst

em c

an b

e di

agno

sed

by

the

incr

ease

d C

SF

dop

amin

e/pr

olac

tin r

atio

eve

n w

ith n

o ne

urol

ogic

al r

espo

nse.

Ou

r cl

inic

al r

esea

rch

sugg

este

d th

at t

he C

SF

-dop

amin

e/pr

olac

tin r

atio

inc

reas

ed b

etw

een

3 an

d 14

day

s af

ter

mus

ic e

mot

iona

l st

imul

atio

n an

d re

cord

ed n

euro

nal

reco

very

fro

m v

eget

atio

n. N

o pa

tient

s re

cove

red

from

veg

etat

ion

with

out

resp

onse

of

the

CS

F

dopa

min

e/pr

olac

tin

ratio

. E

ffect

ive

stim

ulat

ion

of t

he d

opam

ine

A 1

0 ne

rvou

s sy

stem

in

clud

es p

harm

acol

ogic

al

dopa

min

e re

plac

emen

t th

erap

y, e

stro

gen

patc

h th

erap

y,

med

ian

nerv

e st

imul

atio

n, a

nd m

usic

the

rapy

. T

he b

ig

resp

onse

s of

the

CS

F d

opam

ine/

prol

actin

rat

io t

o em

otio

nal

body

con

tact

and

mus

ic t

hera

py w

ere

impr

essi

ve.

How

ever

, m

ore

effe

ctiv

e m

etho

ds o

f ac

tivat

ion

of t

he d

opam

ine

A 1

0 ne

rvou

s sy

stem

are

stil

l un

der

rese

arch

. •

Re

sto

rati

on

th

era

py

for

veg

eta

tio

n:

in t

he c

hron

ic s

tage

, re

spon

se o

f th

e do

pam

ine

A 1

0 ne

rvou

s sy

stem

sho

wn

as i

ncre

ased

of

CS

F d

opam

ine/

prol

actin

rat

io i

s an

ess

entia

l fa

ctor

fo

r su

cces

sful

neu

rona

l re

cove

ry f

rom

veg

eta

tion.

How

ever

, co

rtic

al n

euro

nal

resp

onse

is

also

im

port

ant

for

rest

orat

ion

from

veg

etat

ion.

Ou

r pr

elim

inar

y cl

inic

al

stud

ies

of n

euro

tran

smitt

er r

espo

nsiv

enes

s us

ing

mus

ic t

hera

py s

ugge

sted

tha

t in

crea

sed

CS

F e

pine

phrin

e an

d ho

mov

anill

ic

acid

, an

d sm

all

resp

onse

s of

C

SF

al

anin

e,

glut

amin

e,

and

5-hy

drox

yind

olea

cetic

ac

id

sugg

est

good

pro

gnos

is f

or

reco

very

fro

m t

he v

eget

ativ

e st

ate.

H

owev

er,

incr

ease

s of

CS

F a

lani

ne,

glut

amin

e, a

nd 5

-hy

drox

yind

olea

cetic

aci

d ar

e ne

gativ

e in

dica

tion

for

vege

tatio

n th

erap

y.

It w

as

surp

risin

g th

at t

he

rele

ase

of

neur

otox

ic n

euro

tran

smitt

ers

was

rec

orde

d in

res

pons

e to

em

otio

nal

mus

ic s

timul

atio

n in

cas

es o

f po

or p

rogn

osis

fo

r re

cove

ry f

rom

veg

etat

ion.

Res

pons

e of

the

dop

amin

e A

10

nerv

ous

syst

em a

nd d

opam

ine

and

nore

pine

phri

ne

rele

asin

g ne

uron

s,

and

slig

ht r

espo

nses

of

neur

otox

ic t

rans

mitt

er-r

elea

sing

ne

uron

s ar

e im

port

ant

fact

ors

for

reco

very

fro

m v

eget

atio

n. T

he m

echa

nism

of

prol

onge

d br

ain

dam

age

and

the

resp

onsi

vene

ss o

f ne

urot

oxic

tran

sm

itter

rel

ease

to

emot

iona

l st

imul

atio

n m

ust

be c

onsi

dere

d fu

rthe

r. I

ntra

cere

bral

dop

amin

e re

plac

emen

t th

erap

y an

d su

ppre

ssio

n of

the

neu

rona

l act

ivity

that

rel

ease

r gl

utam

ate,

ala

nine

, an

d 5-

hydr

oxyi

ndol

eace

tic a

cid

is a

n ar

ea

of f

utur

e tr

eatm

ent.

• N

eu

rore

ha

bili

tati

on

: th

e ea

rly p

lann

ing

of n

euro

reha

bilit

atio

n is

ver

y im

port

ant.

How

ever

, th

is b

ook

does

not

di

scus

s ne

uror

ehab

ilita

tion

ther

apy.

w

......

0'1 >

"0

"0

(J) t::l

0..

~. ~ "'"

~

'i:I

po So

:;:; ~ o """ t;O .., po S" ~ o So

(J) .., 3 ;"

~

(J)

po s (J

) a


Management of dopamine A 10 nervous system in severely brain-injured patients

1. Acute stage: prevent dopamine release and use radical scavengers Prevent dopamine release in hypothalamus by administration of metoclopramide Brain hypothermia: 32°-34°C, prevent cerebral dopamine release and radical attack to the dopamine A 10 nervous system Replacement of prolactin and thyroid hormone Administration of radical scavengers

2. Chronic stage: activate dopamine A 10 nervous system Cerebral dopamine replacement therapy

Pharmacological treatment: Levodopa (300-400 mg/day), Amantadine (100-200 mg/day) Uptake of cerebral dopamine: Estrogen (Estraderm TIS Patch 2 mg/day) Median nerve stimulation: 1 0-20 mA 20s on 30s off, 30 pulse/s, duration time 30m/s

Music therapy

Subject Index

A A10 nervous system 75,82,83,89,90,106,237 abdominal hypertension 186 abdominal pressure 122,186,222 acute brain swelling 46, 78 acute onset of cerebral infarction 254 acute renal failure 214

-: basic management 213 -: complication 214 -: diagnosis 213 -: information 213 -: medication 213 -: pathophysiology 213 -: special consideration 214

adequate oxygenation 78, 106, 138 alcohol cooling 131 algorithm

- care management 278 - for ICP elevation 202 - for low blood pressure 202 - for malnutrition and diarrhea 211 - for pulmonary infection 202 - for renal insufficiency 211 - for unstable brain tissue temperature 199 - management 205,279,281,282,284,286,288

- of brain tissue temperature 200 - of hypotension: medication 203 - system 198

aluminum sheet 132 anaerobic brain metabolism 79,111 anaerobic metabolism 79 analgesic agents 145 anesthesia for surgery 141 antibiotics 112, 151,230 anti-Ca++ 171 anti-epieptic medicines 187 antimicrobial therapy 195 antipyretics medication 201 antithrombin III (AT-III) 71,122,150,152 apoptosis 30 arginin 116 aspiration pneumonia 173 atmospheric pressure 133, 159,228

automatic control device for hypothermia 127 autoregulation mechanism 46

B bacterial infection 193 bacterial translocation 194,231 basic care plan 278,279,281,283,285,287 beam balance 16 bed design for brain hypothermia 132 behavior 243

- disturbances 243 behavioral outcome 3 beta-amyloid precursor protein (beta-APP) 14 beyond indication and contraindication 98 biochemical CSF monitor 161,229 biochemical monitoring 229 biphasic effects of hypothalamus-pituitary-adrenal

(HPA) 56 bladder temperature 19,227 blood core temperature 77 blood gases 148 blood-borne exogenous neurotransmiter 25 blood-brain barrier (BBB) 3,25, 139, 190

- dysfunction 64,66,70,103,111,118,137,140, 172,220

- function 69 brain

- !bladder temperature ratio 223 - cooling technique 126 - damage by hypothalamus-pituitary-adrenal

neurohormonal excess reactions 68 - damage caused by hyperglycemia 62 - edema 44, 78 - hypoxia 79 - injury mechanism 48 - ischemia 47 - metabolism 47,71,143,161,162 - monitoring and management 279,280,282,284,

286,287 - oxygen metabolism 154 - stem infarction 255 - swelling 44

319

320 Subject Index

- temperature 49 - thermo-pooling 37,46,52,57,59,76,269 - thermo-regulation 136 - tissue glucose 66, 71, 86, 162, 179, 190 - tissue glutamate 84,139,162 - tissue glycerol 84 - tissue lactate 71,84, 179, 183 - tissue oxygen 161 - tissue pyruvate 72 - tissue temperature 57,58,96,120,125,137,225 - trauma 269

C Ca channel inhibitor 171 CAl hippocampal 10

- pathology 7 CAl hippocampus 9 cardiac arrest 7,9,250,268 cardiac index 155 cardiac muscle 152 cardiac output 96, 157 cardiopulmonary arrest 249 cardiopulmonary dysfunction 55 cardiopulmonary resuscitation 272 care management of systemic circulation 167 care map for sepsis 197 care order 278,280,281,283,285,287 catecholamine surge 55, 60, 64 CD4 immune functions 69 cerebral blood flow (CBF) 27, 77, 154

- and brain metabolism 136 - disturbance 57

- and brain metabolism 200 - thresholds for cell function 48

cerebral blood volume 46 cerebral dopamine replacement therapy 108 cerebral perfusion pressure (CPP) 59,112 cerebral resuscitation after cardiac arrest 251 cerebral thermal index (Cn) 154,155,226 cerebral vasospasm 260 c-fos 30 chronic histopathological and behavioral protection

10 coagulation 152 cognitive deficits 16, 243 cold water blanket technique 125, 128 coma 61 comparative indication 97 complete cerebrovascular obstruction (CVO) 254 complication of severe pulmonary infection 69 compromised patient 95 computed ICU management 199 computed tomography 147

concepts in brain tissue temperature control 120 continuous CSF drainage 262 continuous hemodiafiltration (CHDF) 129 contraction myocytolysis 64 contraindication 95, 97

- for brain hypothermia 173 cooling blanket 18, 165 cooling phase 196 cooling stage (Stage 3) 281 cooling suit 129

- technique 128 cooling water blanket 126 core temperature 18,142 cotton sheet 132 CPP and CBF 77 criteria for brain hypothermia 174 critical path management 277 critical path of brain hypothermia treatment 277 CSF

- cooling technique 129 - dopamine 162,246 - dopamine/prolactin ratio 89,241,242,245 - drainage 185 - epinephrine 162 - neurotransmitter 245 - /serum albumin ratio 69,88, 118 - -ILl 88 - -IL6 88

cyclic AMP 64 cytokine encephalitis 62,70,108,116,143 cytoskeletal pathology 14 cytotoxic brain edema 44

D debridement of necrotic contused brain tissue

143 decompressed semi-closed skull 159 delayed control of hyperglycemia 111 delayed HPA axis suppression by dopamine 81 delayed induction of brain hypothermia 103, 177 delayed vasospasm 259 design of the intensive care unit 133 diarrhea and nutrition

-: basic management 212 -: complications 212 -: diagnosis 211 -: information 211 -: medication 212 -: pathophysiology 211 -: special considerations 212

difference in brain injury mechanism in patients and experimental laboratory models 74

digastrics decontamination 108, 222

digestive organs 136 direct administration of oxygen 142 direct blood cooling hemodiafiltration technique

251 direct blood cooling system 130 direct brain injury 90 disseminated intravascular coagulability (DIe) 170,

195,197 - management 196

disturbances to memory 89 dobutrex 203 DOPAC 238 dopamine 203, 238

- A10 89 - central nervous system 237 - diagnosis of-nervous activity 241 - diagnostic method of responsiveness of the -

nervous system 89 - nervous 82, 83, 90

- system 75, 239 - -dominant systemic circulation 57 - metabolite 238 - nervous system 79 - replacement therapy 108,246

disphosphoglycerate (DPG) 63,114 - hemoglobin - 148,168,249,250

draining of subcutaneous CSF 143 duration of brain hypothermia 121, 124 dysoxia 156

E early induction of brain hypothermia 103,262 early induction of mild to moderate brain

hypothermia 85 early management of pulmonary infection 193 ebb phase 191 effectiveness of brain hypothermia 270 effectiveness of dopamine replacement therapy

246 efficacy of brain hypothermia 269 elastic bandage technique 148 electrocardiogram (ECG) 151 emergency cardiopulmonary bypass 251 emotional center 75,89,243 end tidal CO2 (ETC02) 167 enteral-intestinal 112 entry criteria 273 epinephrine 60 estrogen 237 excess release of vasopressin 74 excitatory amino acids 23 excitatory neurotransmitters 51 externally decompressed skull 46

F fibrinolysis 152 flow phase 191 fluid resuscitation 135

- at Induction Stage 170 fluid selection 188 fluorocarbon oxygen carrier 142 free radicals 24,83,103,182

Subject Index 321

fundamental technique of brain tissue temperature control 125

fungemia 197

G gastric lavage 154 gastric pHi 152, 170,231 gin reactions 48 glasgow outcome score 270 glucose metabolism 169 glutamate 23

- (IlmoIlL) 140 glycerol 140 glycogenesis of protein 81 growth hormone 69,195

H harmful stress stimulates the HPA axis 177 Hayashi catheter (H-catheter) 158,159 hazards of hypothermia 51 Hb-DPG 63,64,168,249,250 head position 148, 185 heat-generating medical devices 133 hemoglobin dysfunction 38,52,64,68,79,261 herniation 160 history of clinical trials of hypothermia 51 hsp70 30 hyperglycemia 61,64,111,149,178,219,255,262 hyper-metabolism 230 hyperthermia 18, 19,21 hypertonic crystalloid solutions 178 hypo-albuminemia 71,112,149,150 hypopituitarism 180 hypotension 21

-: basic management 203 -: complications 204 -: information 202 -: pathophysiology 203 -: special considerations 204

hypothalamus dysfunction 180 hypothalamus-pituitary-adrenal axis (HPA) 37,

55,250 - axis neurohormonal abnormality 254, 262 - axis stimulation 262

322 Subject Index

- dysfunction 90 - neurohormonal dysfunction 261 - stimulation 52

hypothermia anesthesia 51 hypoxia 21,156

I ICU management strategies 68 IL-10 32 immune dysfunction 69,117,191 immunocompromised host 193 improper management of brain hypothermia 110 inadequate brain temperature 71 inadequate nutrition 117 indication 97

- and criteria for dopamine replacement therapy 246

- of rewarming 214 - to stop hypothermia 198

indirect evaluation methods of monitoring 137 indirect method of brain hypothermia 125 indirect parameter of BBB dysfunction 139 induction of brain hypothermia treatment 165

- stage 1 278 - stage 2 279

ineffective oxygen inhalation 249 infection 192 infectious control 69,192-194 inflammatory cytokine 10 initial management 85 inner consciousness 235 inner cool by celsius control system 129 insertion of catheter 157 insulin resisted hyperglycemia 38, 60, 81, 104, 245,

249,261 intensive care management 108 interleukin-1 beta 30 internal jugular venous blood temperature 58, 77 intervention 278, 280, 281, 283, 285, 287 intestinal mucous membrane edema 112 intra-abdominal balloon catheter 80 intra-abdominal balloon pumping 251 intracranial hypertension 45 intracranial pressure (ICP) 112,137,184,228

- elevation 45 - at the rewarming stage 229 -: basic management 205 -: complications 206 -: diagnosis 205 -: information 205 -: medication 206 -: pathophysiology 205 -: special considerations 206

intravenous medication 279-281, 284, 285 irrigation of brain tissue 142 ischemic brain insults 99 ischemic duration 9

J jugular venous blood catecholamines 81 jugular venous blood temperature 160,225 jugular venous oxygen saturation (Sj02) 160 J-wave (Osborn wave) 152

L L-arginine 195 late induction of brain hypothermia 104 lipid metabolism 169 lipid peroxidation 24, 172 localized tissue temperature 225 long-term effects 12 low molecular weight heparin 184 lymphocytopenia 69

M macronutrient 71, 189

- feedback mechanism 65 - intake 87

maintenance of cerebral blood flow (CBF) 148 maintenance of microcirculation 138 major targets of brain hypothermia treatment 52 management

- care point at each stage 113 - choice 87 - during the cooling stage 175 - of BBB dysfunction 183 - of blanket water temperature 126, 127 - of brain tissue temperature 125 - of cardiopulmonary function 167

- during brain hypothermia 250 - of cerebral vasospasm 263 - of CPP 80 - of digestive organs 188 - of dopamine A10 nervous system 239 - of emotion 243 - of hemoglobin dysfunction 178 - of HPA axis neurophormone dysfunction

179 - of metabolic substrates and hyperglycemia

168 - of microcirculation and vascular inflammation

170 - of neurohormonal dysfunction 80 - of neuronal oxygenation 168

- of pulmonary infection 196 - at rewarming stage 230

- of rewarming 224 - of serum glucose 219 - of swan ganz catheter 157 - plans for brain tissue temperature 107

manito I and glycerol 110 masking neuronal hypoxia 37,52,62,63,104,113,

114 mechanism

- after severe subarachnoid hemorrhage 263 - of brain damage 43, 74, 90 - of emotional disturbance 243 - of hyperglycemia 60 - of vegetation 237

median nerve stimulation 244 medication 287 memory 243 metabolic ebb phase 189, 190 metabolic flow phase 189, 190 metabolic shift from glucose to lipid 169 metabolic substrate 78 metabolism of macronutrients 179 microdialysis 71

- catheter 143 - monitor 143,161

micro nutrients 189 microtubule-associated protein 2 (MAP-2) 14 midazolam 145 mild brain hypothermia 51, 120, 176

- management 166 - treatment 120, 122

moderate brain hypothermia 107,120,121,135, 176

- management 166 - treatment 120, 123

monitor 135, 157 - for ICU management 138,143

monitoring 147 - and management of systemic homodynamic

changes 279,280,282,284,286,287 - at the rewarming stage 225 - brain tissue temperature 225 - cardiac output 155, 158 - ICP 157 - of tympanic membrane temperature 226 - jugular venous blood temperature 158 - tympanic membrane temperature 226 - vital signs 147

muscle relaxants 145,185 muscle weakness 220, 221 music therapy 239,242 myelinated axons 19 myeloperoxidase (MPO) 28

Subject Index 323

N neurohormonal BBB dysfunction 79 neuroimmune function 200 neuron protection 76,141 neuronal damage 3 neuronal function 136 neuronal hormones 177 neuronal hypoxia 148,174,263 neuronal restoration 38 neuronal toxicity by glutamate 183 neuropeptide Y 88

- receptors 183 neuroprotection 44

- by glia 48 - therapy 181

neuroprotective agent 171 neurotoxic hydroxide radicals 75 new brain injury mechanism after subarachnoid

hemorrhage 260 new concept of brain hypothermia treatment 85,

269 new concept of unconsciousness 237 NF-kappaB 28 NIH stroke scale 256 nitric oxide synthase (cNOS) 26 N02/N03 163

- ratio 182 NO radicals 82, 163, 182 non-filling 155 nonfunctioning antibiotics 112 noninvasive monitoring 138

- of brain damage 137 nonperfusing ventricular tachycardia 272 nonspecific brain damage 90 normothermia treatment 269 normovolemic fluid resuscitation 167,184 nutritional considerations 191,221

- at the rewarming stage 231 nutritional management 189

o occlusive cerebral stroke 254 OH- radical 104 old-age patients 61 osmotic management 185 other treatment 186 outer consciousness 231 outline of the critical path 278 oxygen consumption 64, 156 oxygen delivery 64,80,114,156 oxygen extraction ratio (02ER) 155 oxygenation 138

324 Subject Index

p

PaC02 148,188 Pa02IFi02 168,251 parasagittal fiuidpercussion 12 parenteral nutrition 118 pathophysiology 22 PCPS 251,272 personality 89 pharmacological cooling 131 pharmacological neuroprotection 170 pharmacological treatment 178

-: levodopa 244 - of muscle weakness 221

phenobarbital 187 pitfall of brain hypoxia and ischemia 62 pitfalls of brain hypothermia treatment 108,111,113 pitfalls of rcp management 186 pituitary hypothermia 180 pituitary hormones 69 pituitary hypo-function 117,191 platelet 152

- count 122 pneumoma

-: basic management 208 -: complications 209 -: diagnosis 208 -: information 208 -: medication 208 -: pathophysiology 208 -: special considerations 210

polymorphonuclear leukocytes (PMNLs) 28 poor enteral care management 192 poor filling ischemia 155 posthypothermia stage (Stage 6) 287 preconditioning for rewarming 219

- (Stage 4) 283 preliminary refrigeration 165 presynaptic glutamate inhibition 171 prevention

- of acute brain swelling 229 - of brain edema 173, 184, 229 - of brain thermo-pooling 181 - of brain tissue lactate 87 - of convulsion 187 - of dopamine release 239 - of excess release of cerebral dopamine 182 - of excess release of cerebral glutamate 182 - of hypokalemia 198 - of immune crisis 190 - of infection 138, 192 - of nitrous oxide radical 172 - of pulmonary obstruction 186 - of rewarming stress 123 - of selective damage to the hippocumpus 83

- of systemic infections 222 - of vasopressin release 172 - of vegetation 106,245

prognosis - brain trauma 270 - cardiac arrest 237

proinfiammatory cytokines 69 prolonged anesthesia 145 prolonged moderate hypothermia 69 propofol 145 protection of BBB 195 protein binding type antibiotics 151 protein kinase C activity 30 protein synthesis 51 protocol for brain hypothermia 106 pseudomonas aeruginosa 197 PTCA 251 pulmonary infection 115,116,139,194

Q QT interval less 174

R rapid induction of brain hypothermia 87 rapid induction of moderate brain hypothermia

110 rapid progression of hyperglycemia 87 rapid rewarming 20 reactive oxygen species 24 rebleeding of a silent hematoma 147 reduced Hb-DPG 114 reduced immune function 116 regulation mechanism of brain tissue temperature

58, 76 rehabilitation of muscle weakness 221 release of dopamine 75 release of vasopressin 88 removal of infectious source 194 reperfusion 59 restoration therapy 68

- for injured neurons 176 reversibility of severe brain injury 98 reversibility of the vegetative state 241 rewarming 124

- clinical issues for management of- 217 - from mild brain hypothermia 224 - from moderate brain hypothermia 224 - phase 20,196 - stage (Stage 5) 285 - time 108, 123, 124, 217

rubber sheet 132

S sadation 185 safe induction of moderate brain hypothermia 127 selection of mild or moderate brain hypothermia

treatment 107 selective brain-cooling technique 125 selective OH- attack 82 selective radical damage of dopamine AlO 79,90,

106,237 semi-closed skull 157 sepsis 195 serum albumin 220 serum glucose 252, 261 serum magnesium 171,222 serum N02 and N02/N03 ratio 104 serum phosphate 222 shock patients 177 short duration of brain hypothermia 68, 115, 124 sick euthroid syndrome 238 Sj02 137 slow onset of cerebral infarction 255 slow rewarming 20 spatial memory performance 16 Spiel Berg ICP sensor 158 spinal cord ischemia 16 stabilize autonomic nerve reactions 201 stage care plan 277 standard care 278 standard management 279,281,283,285,287 staphylococcus aureus 197 steroid 79, 172

- administration 44 stimulation of the HPA axis 74 strategies for management of ischemic brain 256 stress-associated hyperglycemia 61,177,260

- after cardiac arrest 252 stress-induced catecholamine surge 37 stress reactions 56 stress to the HPA-axis 38 subarachnoid hemorrhage 258 supporting cooling method 130 surgical considerations 142 surgical position 141 suspected acute coronary syndrome 247 Swan Ganz catheter 136 systemic hemometabolism 153, 156 systemic metabolic shift 115

T target of treatment of severe brain injury 78 TBI complicated by secondary hypoxia 20

Subject Index 325

technique of H-catheter insertion 160 technique of rewarming 224 thrombolytic agents 10 thrombomodulin 152 time schedule for management of brain tissue

temperature 121,166,175 transient MCA occlusion 7 transluminal coronary angioplasty (PTCA) 272 triple H therapy 170, 171, 256 two-step induction of hypothermia 173 tympanic membrane temperature 58, 154, 226

U unconsciousness 231,237 uncontrollable hyperglycemia 95 uncontrolled hyperglycemia 115 unstable immune functions 201 unstable metabolic conditions 201 unsuccessful cooling of brain tissue temperature

200 unsuccessful hypothermia treatment 68 uptake of cerebral dopamine 244 urinary drainage 153

V vancomycin 150 vascular engorgement 43, 181 vasogenic brain edema 44 vasopressin 65,168,190,258

- release 64, 81, 261 vasospasm 258-260 vegetative state 73,235,238 venous stasis 45 ventricular fibrillation 272 ventricular tachycardia (VT) 249 vitamin A 122

W washing the clot of basal cistern 262 waterfall pressure 45 whole brain tissue temperature 77

y young children 61

Z ZnCI 116

Appendix. Critical Pathway of Brain Hypothermia Treatment978-4-431-53953-7/1.pdf · Appendix....

Documents

Transcript of Appendix. Critical Pathway of Brain Hypothermia Treatment978-4-431-53953-7/1.pdf · Appendix....