COURTNEY J. COOK, DNP, ACNP-BC Induced Hypothermia in Neuro-critical Care: ESTABLISHING A...
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Transcript of COURTNEY J. COOK, DNP, ACNP-BC Induced Hypothermia in Neuro-critical Care: ESTABLISHING A...
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COURTNEY J. COOK, DNP, ACNP-BC
Induced Hypothermia in Neuro-critical Care:
ESTABLISHING A STANDARDIZED SHIVERING ASSESSMENT AND
TREATMENT PROTOCOL
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PROBLEM STATEMENT
• In neurocritical care, the use of induced hypothermia (IH) is an emerging treatment modality for the management of:• Refractory intracranial hypertension • Cerebral edema
• Shivering is a common complication of IH.
• In this project, the Neuroscience Intensive Care Unit (NSICU) studied at a level I Trauma Center lacked a standardized shivering assessment and treatment protocol.
• Aim of Project: Establish a protocol to provide a consistent and reliable measurement of shivering and corresponding treatment algorithm.
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BACKGROUND AND KEY CONCEPTS DEFINED
• Induced hypothermia (IH): 33-35°C.
• Indications: Malignant cerebral edema or refractory intracranial hypertension
• Traumatic brain injury (TBI), malignant ischemic stroke, subarachnoid hemorrhage (SAH), and intracranial hemorrhage (ICH)
• Reduces cerebral edema, intracranial pressure, and metabolic demands
• Shivering defined3
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SIGNIFICANCE OF PRESSURE AND EDEMA IN THE CRANIAL VAULT
• Monro-Kellie hypothesis:
Cranial vault (v)=brain matter(v)+ csf(v)+blood(v)+tumor(v)
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HOW IH IS PERFORMED
•Endovascular cooling
•External (surface cooling)
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COMPLICATIONS OF IH AND THE SIGNIFICANCE OF SHIVERING
• Complications effect tissues at the molecular level and ultimately have repercussions for multiple organ systems.
• Shivering has the potential to increase metabolic demands by up to 600% (Badjatia et al, 2008).
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TEMPERATURE REGULATION
• Achieved through cutaneous vasodilation and sweating or vasoconstriction and shivering in order to maintain homeostasis 37°C, or 98.6°F.
• Two heat capacitances (energy storage units): • 1. core • 2. skin
.
7(Guyton & Hall, 2011).
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THE ROLE OF SHIVERING IN TEMPERATURE REGULATION
• Standard heat production from shivering is 252 kcal/hr
• Example: If skin heat loss from radiation is 80 kcal/hr, the skin temperature gradient will double.
(Riggs, 1970)
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THE MULTIPLICATIVE FACTORS
• Two primary factors influence the multiplicative factors
• 1. the shivering initiation multiplier (from the cooler core temperature)
• 2. the shivering multiplier from the normalized temperature difference
(Riggs, 1970) 9
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THE SECOND MULTIPLICATIVE FACTOR
• Also known as the “normalizing factor,” K, and is dependent on core temperature
• When the temperature falls below 37°C, a linear relationship exists that allows for the K to be determined.
• For instance, if the core temperature is 35°C, then K is 25°C
(Riggs, 1970) 10
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THE SUMMATION OF THE MULTIPLICATIVE FACTORS
(Riggs, 1970)11
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CURRENT PRACTICE IN THE NEUROSCIENCE INTENSIVE CARE UNIT (NSICU)
• Induced hypothermia is achieved via surface cooling.
• Goal temperature is 35°C
• Shivering is inconsistently assessed as either present or absent (observational)
• Pharmacologic management typically involves propofol infusions, fentanyl (IV boluses prn), and versed (IV boluses prn)
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ESTABLISHING A PROTOCOL FOR SHIVERING ASSESSMENT AND
MANAGEMENT
• Comprehensive literature review
• Synthesis of information is limited by gaps in the literature.
• Lack of randomized clinical trials
• No standard IH goal temperature (ranging from 32°C to 35°C).
• Newer modality and therefore, less research has been conducted.
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METHODOLOGY
• The Deming Model: Plan, Do, Study, Act (PDSA) theoretical framework
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METHODOLOGY CONTINUED
• Plan: A needs assessment was be conducted.
• A comprehensive approach allowed for firm understanding of current practice and limitations
• Do: Incorporating the Columbia BSAS into the final NSICU protocol was the aim since it has been validated through clinical research.
• The pharmacological algorithm was be revised to address medications identified in multidisciplinary literature (anesthesia, neurology, pharmacology).• Demerol and Ondansetron
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METHODOLOGY CONTINUED
• Study: A retrospective chart review was completed on all patients receiving IH from January 1, 2012 through January 1, 2013
• Goal N=30
• The literature review provided the foundation for drafting the proposed shivering assessment and management protocol.
• The areas of clinical interest for data collection were as follows:
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AREAS OF RESEARCH INTEREST
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METHODOLOGY CONTINUED
• Act: The proposed protocol will require a clinical research study to evaluate efficacy and impact on patient outcomes. This may be a future extension of this research project.
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THE COLUMBIA BEDSIDE SHIVERING ASSESSMENT SCALE (BSAS)
(Badjatia et al, 2008). 19
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THE COLUMBIA SHIVERING TREATMENT ALGORITHM
(Badjatia et al, 2008) 20
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(Weant et al., 2010)21
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THERAPEUTIC CLASSES AND EFFECTS
• Nonopiod analgesics (acetaminophen)
• Anxiolytics (buspirone)
• N-methyl-D-aspartate receptor agonists (Magnesium)
22(Weant et al., 2010)
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THERAPEUTIC CLASSES CONTINUED
• A2-adrenergic agonists (dexmedetomidine, opiates)
• Narcotic Analgesics (fentanyl, meperidine)
• General anesthetics (propofol)
• Paralytics (vecuronium)
(Weant et al., 2010) 23
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THERAPEUTIC CLASSES CONTINUED
• Additional medications considered for incorporation into the shivering management protocol that were not included in the BSAS:
• Ondansetron (5 HT agonist)
• Tramadol (inhibits norepinephrine/serotonin uptake)
• Clonidine (A2 agonist)
• Nalbuphine (mixed agonist-antagonist opioid)
• Dantroline (inhibits skeletal muscle excitation-contraction coupling)
• Doxapram (stimulates dopamine release)
24(Weant et al., 2010).
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CONCLUSION
• Purpose-Establish a Shivering Assessment and Treatment Protocol in the NSICU
• Methodology-Deming Model for continuous quality improvement• Data Collection-retrospective chart review January 1, 2012 through
January 1, 2013• Goal N=30• Through literature review, consider additional pharmacologic options
to reduce shivering.• Present protocol to Nursing Policy and Standard Committees for
review• Moving forward-consider a formal research study as a future
extension of this project to follow implementation and clinical outcomes
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QUESTIONS?
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REFERENCES:
• Ash, L. (2000) Counter Current Heat Exchange. Retrieved from: http://www.biology.ualberta.ca/facilities/multimedia/uploads/zoology/counter%20current.html
• Badjatia, N. (2006). Therapeutic temperature modulation in neurocritical care. Critical Care Neurology, 6: 509-517.
• Badjatia N., Strongilis, E., Gordon, E., Prescutti, M., Fernandez, L., Fernandez, A…Mayer, S. A. (2008) Metabolic impact of shivering during therapeutic temperature modulation. Stroke, 39:3242-3247.
• Benzinger, T. H. (1963). “The Human Thermostat” Temperature, Its Measurement and Control in Science and Industry (637-665). New York: Reinhold Publishing.
• Bernard, S.A., & Buist, M. (2003). Induced hypothermia in neurocritical care medicine: a review. Neurologic Critical Care, 31(7) 2041-2051.
• Bhardwaj, A., Alkayed, N.J., Kirsch, J.R., Traystman, R.J. (2007). Acute Stroke: Bench to Bedside (Neurological Disease and Therapy). Informa Healthcare USA. New York, NY.
• Choi, H. A., Sang-Bae, K., Presciutti, M., Fernandez, L., Carpenter, A. M., Lesch, C…Badjatia, N. (2011). Prevention of shivering during therapeutic temperature modulation: The Columbia anti-shivering protocol. Neurocritical Care Society, 14, 389-394.
• Deming, W.E. (1950). Elementary principles of the statistical control of quality-a series lecture. Japanese Union of Scientist and Engineers.
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REFERENCES CONTINUED
• Doufas, A. G., Lin, C. M., Suleman, M. I., Liem, E. B, Lenhardt, R., Morioka, N…Sessler, D. I. (2003). Dexmedetomidine and meperidine additively reduce the shivering threshold in humans. Stroke, 34, 1218-1223.
• Ford, A. (2012). Physiology exercises: Body temperature control with shivering. Retrieved from: http://public.wsu.edu/~forda/Physiology.pdf
• Geocadin, R. G. & Carhuapoma, J. R. (2005) Medivance arctic sun temperature management system. Neurocritical Care, 3, 63-67.
• Guyton & Hall (2011). Medical Physiology. Saunders: Philadelphia, PA. • Hand, H., Searcy, M., Schulman, C.S. (2011). Shivering avoidance in the neuronally
injured patient: Impact on temperature management technology decisions• Kochanek, P. M. (2009). The brain, the heart, and therapeutic hypothermia. Cleveland
Clinic Journal of Medicine, 76, S8-S12.• Lenhardt, R., Sungur-Orhan, M., Komatsu, R., Govinda, R. Kasuya, Y., Sessler, D. I.,
Wadhwa, A. (2009). Suppression of shivering during hypothermia using a novel drug combination in healthy volunteers. Anesthesiology, 111(1), 110-5.
• Liu-DeRyke, X. & Rhoney, D.H. (2008). Pharmalogical management of therapeutic hypothermia-induced shivering. Society of Critical Care Medicine.
• Logan, A., Sangkahand, P., & Funk, M. (2011). Optimal management of shivering during therapeutic hypothermia after cardiac arrest. Critical Care Nurse, 31(6):e18-e30.
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REFERENCES CONTINUED
• Marshall, P.S. & Siegel, M.D. (2009). Therapeutic hypothermia. American College of Chest Physicians (23): 1-17.
• Miller, C.A. (2011). Pharmacological treatment of post-anesthetic shivering: an educational outreach project. Texas Christian University Harris College of Nursing and Health Sciences, 1-57.
• Mokri, B. (2001). The Monro-kellie hypothesis: Applications in CSF volume depletion. Neurology, 56(12):1756-1748.
• Mokhtarani, M., Mahgoub, A. N., Morioka, N., Doufas, A. G., Dae, M., Shaughnessy, T. E…Sessler, D, I. (2001). Buspirone and meperidine synergistically reduce the shivering threshold. International Anesthesia Research Society, 93, 1233-1239.
• Paulev, P.E. & Zubieta-Calleja, G.Z. (n.d.) New Human Physiology. Chapter 21: Thermo-regulation, temperature, and radiation. Retrieved from: http://www.zuniv.net/physiology/book/chapter21.html
• Riggs, D. (1970). The mathematical approach to physiological problems. Baltimore: Williams & Wilkins.
• Ropper, A. H. (2012). Hyperosmolar therapy for raised intracranial pressure. The New England Journal of Medicine, 367:746-752.
• Sakoh, M. & Gjedde, A. (2003). Neuroprotection in hypothermia linked to redistribution of oxygen in brain. American Journal of Physiology: Heart and Circulatory Physiology, 285(1):H17-25.
• Weant, K.A., Martin, J.E., Humphries, R.L., Cook, A.M. (2010). Pharmacologic options for reducing the shivering response to therapeutic hypothermia. Pharmacotherapy, 30(8); 830-841.
• Witte, J.D. & Sessler, D.I. (2002). Perioperative shivering: physiology and pharmacology. Anesthesiology, 96(2):467-484.
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