SCHOLARLY PAPER 1

CNS Role Specialty Practicum I: Scholarly Project Paper

Translating Evidence into Practice: Therapeutic Hypothermia in Adult Post Cardiac Arrest

Patients

Roshan Jan Muhammad

The Johns Hopkins University School of Nursing

“On my honor, I pledge that I have neither given or nor received any unauthorized assistance on

this assignment”. RJM

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Abstract

Despite successful cardiopulmonary resuscitation (CPR), the victims of cardiac arrest

(CA) have grave prognosis. The most common cause of mortality among post CA patients is

anoxic brain injury that accounts for two third deaths in these victims (Stub et al., 2011). This is a

consequence of pathological events at cellular level secondary to disrupted calcium homeostasis,

free radical formation, and activation of cell-death signaling pathways (Neumar et al., 2008).

Therapeutic hypothermia (TH) is recommended as a part of post CA care by International Liaison

Committee of Resuscitation (ILCOR) to halt the adverse effects of ischemia on brain; and it is

associated with reduced mortality and improved neurological outcome in post CA patients (Nolan

et al. (2010)). The purpose of this project was to transform post CA care at the Medical/Surgical

Intensive Care Unit (ICU) of the Aga Khan University Hospital (AKUH) by introducing evidence

based TH intervention. This pilot project was guided by Complex Adaptive Systems Theory of

change. It encompassed need assessment of the institution; multidisciplinary teambuilding;

evidenced based protocol development though systematic review; establishment of process

monitoring and outcome analysis; resource mobilization; clinical capacity building of the nursing

staff; implementation; and execution of measures to ensure sustainability. The success of this

pilot project, which is planned for 9 months, would open the avenue of replication to other units

like Emergency, Coronary Care Unit and Cardiothoracic Care Unit.

Key words: Therapeutic hypothermia (TH),Cardiac arrest (CA), return of spontaneous

circulation (ROSC), shockable rhythm (ventricular fibrillation or pulseless ventricular

tachycardia), non-shockable rhythm (Asystole or pulseless electrical activity), neurological

outcome, mortality, in-hospital, out of hospital cardiac arrest (OHCA)

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Introduction

CA and related mortality and morbidity are commonly encountered phenomena in a

hospital setting. Despite aggressive measures, the outcome post cardiac arrest is still poor, with

only 7% to 30% of the patients being discharged from hospital with good neurological outcome

(Granja et al., 2011). According to Neumer et al. (2008), CA causes global ischemia, nonetheless,

brain is most vulnerable to the adversity of poor perfusion. Neurological damage starts within

four to six minutes of CA, if CPR is not initiated. Nevertheless, effective CPR only partially

restores perfusion to the vital organs (Cour et al., 2011). While ischemia during CA is damaging

to the brain, evidences also suggest that reperfusion post return of spontaneous circulation

(ROSC) compliments initial hypoxic insult and perpetuates mitochondrial dysfunction and

cellular death (Cour et al., 2011). Consequently, those who survive from CA suffer serious

debilitating neurological complications or die due to post cardiac arrest syndrome (Stub et al.,

2011). The risk of poor neurological outcome increases with each degree increment in body

temperature above 37C post ROSC (Nolan et al., 2010).

Mild TH that ranges from 32C to 34C, is known to improve neurological outcome of

post CA patients through various neuro-protective effects (Nolan et al., 2010). During the project,

I reviewed and synthesized evidences on the role of TH in post CA patients; converged evidences

to develop clinical protocol; and initiated pilot project to assess the feasibility of implementing

TH for adult post CA patients in the ICU of the AKUH.

Assessment of Organizational Need

For this project the facility of AKUH was selected, which is a tertiary care teaching

hospital in Karachi, Pakistan. AKUH is also one of the training centers of the American Heart

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Association (AHA), which is determined to improve the process and outcome of CA in their

facility. According to the CPR committee of the AKUH, total 898 adult patients sustained CA out

of 1,37,355 discharges during the period of 2010 to September 2012 at AKUH, with cumulative

incidence of 6.53 patients per 1000 discharges. Of 898 patients, only 139 patients survived till the

time of the discharge, thus, the overall unadjusted survival to discharge rate is 15.47% in this

cohort. Unfortunately, there is no data available on national incidence of CA and related outcome

in Pakistan. Therefore, the survival rate of CA at AKUH is compared with the findings reported

by the National Registry of Cardiopulmonary Resuscitation of USA. According to the National

Registry, the overall rate of survival to discharge was 22.3% and the rate of survival with good

neurological outcome was 72% in CA patients during 2009 (Girotra et al., 2012). At the time of

assessment, there was no mechanism at AKUH to monitor and follow the cerebral performance of

post CA survivors at the time of discharge, thus, the quantum of problem could not be completely

gauged. However, comparison of the survival rate revealed that there was an opportunity for

AKUH to improve further in this area of health concern.

To improve the survival outcome and salvage the neurological state of post CA victims

require multi-facet interventions. It include high quality CPR; advanced cardiopulmonary

resuscitation (ACLS); optimal support to the vital organs post ROSC; and intervention like

therapeutic hypothermia to minimize the neurological sequel (Stub et al., 2011). AKUH has well

established policies, procedure and mechanisms to address aforesaid critical needs of post CA

patients. All medical staff and paramedics are trained to perform CPR; ACLS trained code team

members respond to the code call, routine mock code drills are performed as a quality

improvement activities and oversight mechanism is established in form of CPR committee.

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However, they have not yet adopted the practice of TH. Nonetheless, leadership of the CPR

committee and clinical leadership of the ICU were motivated to embark on this initiative.

Literature Review

TH is a tri-phasic intervention which typically include; induction, maintenance and

rewarming phase (Stub et al., 2011). According to Beddingfield et al., (2012), TH prevents

astroglial proliferation and blocks the cascade of pro inflammatory mediators. Also, it mitigates

brain damage by reducing cerebral metabolic requirement; decreasing cerebral edema; inhibiting

reperfusion injury; and limiting apoptosis. Despite all goods, hypothermia intervention is not free

of complication. Shivering, electrolyte imbalance, hyperglycemia, hypotension, bradycardia, QT

prolongation, arrhythmias, bleeding and increased risk of infection are few infrequent and

nonfatal side effects of TH (Nolan et al., 2010).

First time, neuro-protective effects of TH were acknowledged in 2002, when two

independent randomized controlled trials (RCTs) by Bernard et al. (2002) and HACA study group

(2002) revealed significant positive outcomes of TH in patients with out of hospital cardiac arrest

(OHCA) with an initial rhythm of ventricular fibrillation (VF). In lieu of these findings, in 2003,

ILCOR recommended the use of TH in the treatment of adult post CA patients (Nolan et al.,

2003). However, the recommendation was restricted to only OHCA victims whose initial rhythm

at the time of CA was shockable. Thereafter, in 2010, scientific statement released by American

Heart Association endorsed the same recommendation based on the findings of subsequent

studies, also expanded the scope of treatment to patients who sustained CA in-hospital and

patients who had initial non-shockable rhythm (Nolan et al., 2010).

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I conducted systematic review on “TH and its impact on neurological and survival

outcomes in adult post cardiac arrest patients” to synthesize evidences and consolidate it into

protocol form to guide practice. Search engines like PubMed, EMBASE, CINAHL and Cochrane

were explored for the period of 2007-2012 using database specific MeSH terms. The search was

truncated to RCT, quasi-experimental studies and non-experimental quantitative studies

conducted on patients over the age of 18years. After eliminating duplication and the review of

abstracts, seventeen articles were found relevant. Of which 10 articles were considered during

synthesis process excluding the low quality (III C) evidences. Of ten articles appraised, two

included RCTs (Tiainen et al., 2007; Kim et al., 2007); one was quasi-experimental study (Granja

et al., 2011); six were retrospective observational studies (Reinikainen et al., 2012; Prior et al.,

2010; Pfeifer et al., 2011; Testori et al., 2011; Stub et al., 2011; Van der et al., 2011); and one

study had prospective observational design (Storm et al., 2012). Key variables of the research

design and the results of the studies are summarized in Appendix A.

Out of ten studies, five studies (Reinikainen et al., 2012; Prior et al., 2010; Testori et al.,

2011; Stub et al., 2011; Van der et al., 2011) showed statistically significant mortality benefit of

TH. Whereas, of eight studies that evaluated neurological effect of the treatment, four revealed

statistically significant positive conclusion in favor of TH (Prior et al., 2010; Pfeifer et al., 2011;

Testori et al., 2011; Stub et al., 2011). Evidences from the landmark RCTs and this systematic

review concluded that there is a substantial evidence to support the use of TH in post CA cases to

improve survival and neurological outcome. Nevertheless, favorable evidences are more inclined

towards CA patients with shockable rhythm in OHCA. There is limited evidence that support the

use of TH in in-hosptial CA and those with non-shockable rhythm. Those with convincing results

are observational studies in which the risk of bias cannot be eliminated and causality cannot be

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established (Prior et al., 2010; Pfeifer et al., 2011). As a result, TH cannot be concluded as a sole

and independent predictor of positive outcome in in-patients CA cases. However, this review

proclaims the synergic effect of TH with other post ROSC interventions to minimize the

neurological damage and improve survival outcomes in in-patient CA group as well.

All the studies had vast differences in terms of study deign, rigor, and methodology. To

summarize, the studies had limitations like selection bias; lack of control over confounding

variables; inadequate standardization of treatment; lack of power analysis; and influence of

history as a threat to internal, external and statistical validity of the studies (Burns and Grove,

2009). As a result, this review could not conclude the best induction time, optimal duration of TH,

therapeutic range of hypothermia, the rate of rewarming, and the best cooling device to manage

TH. Therefore, expert opinion from ILCOR was referenced to extrapolate the window period for

induction, timelines for maintenance phase and optimal rewarming rate (Nolan et al., 2010).

Theoretical framework

Transformation of practice in lieu of evidences is a complex phenomenon that requires

harmonization between health care system and human being involved in the process (Chapman,

2010). Complex Adaptive Systems (CAS) Theory provides a framework for Clinical Nurse

Specialists (CNSs) through which change is better understood, anticipated, designed and

embraced (Chapman, 2010). According to her, there are three core principles of CAS:

relationships; self-organization; and nonlinear predictability. She elaborates that “CAS is a

collection of individuals, whose actions are interconnected (web of relationships) so that agent’s

action changes the context for other agent (self-organization) with freedom to act in a way that are

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not always totally predictable (nonlinear)” (p.100). The author articulates CAS principles in

following four steps approach to guide CNS while embarking on change process.

According to Chapman (2010), the first step is called assessment, in which change agent

identifies potential stakeholders involved during the change process; explores levels of approval

needed to execute innovation; and recognizes how new proposition articulate with organizational

strategic priority. Second step is referred as diagnosis, in which CNS examines the values and

attitudes of the affected stakeholders about the proposed change; assesses organizational

structure; and identifies potential barriers, facilitators and attractors, to plan and prioritize actions.

In third phase interventions are developed and solutions are tested. This phase involves

development of evidence based standards and guidelines; establishment of multidisciplinary

group to bolster adoption of innovation; development of system level policies to support change,

mobilization of resources to reduce system level barriers; and commencement of methodologies

to sustain the program. In final phase, the impact of the program is evaluated through clinical and

financial outcomes measurement; and findings are disseminated. Chapman (2010) also

emphasizes that CNS competencies defined by The National Association of Clinical Nurse

Specialist (2008) are pivotal to addressing the complex components of CAS.

Intervention

The implementation of the project mimicked the aforementioned steps proposed in CAS

framework. It encompassed need assessment of the institution; multidisciplinary teambuilding;

evidenced based protocol development; establishment of mechanism for process monitoring and

outcome analysis; resource mobilization; clinical capacity building of the nursing staff;

implementation; and measures to ensure sustainability.

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During the need assessment process, keeping in view the culture and work politics of the

institute, influential members were identified necessary for approval, teambuilding and propelling

the agenda forward. The team comprised of CPR committee chair, ICU director, and Assistant

Nursing Director of critical care units. Later, the team also invited the Nurse Manager and

Clinical Nurse Instructor (CNI) of the ICU, who was mainstay to develop a clinical work force.

As a next step, evidences extrapolated through systematic review were utilized to

formulate TH protocol and was discussed with stakeholder. After, deliberation with the CPR

committee chair and ICU director, the protocol was redrafted as a policy document that defined

the responsibilities of multidisciplinary team members (Refer Appendix B). A TH monitoring

sheet was also developed in consultation with CPR committee chair and ICU nursing team, to

meet the monitoring and documentation requirement; and to observe practice variance (Refer

Appendix C). The monitoring sheet also included covariates critical for the outcomes analysis.

Detailed capital and operational budget spread sheet was prepared and presented to the

team to assist in planning and resources allocation (Refer Appendix D). However, keeping in

view that ICU was already well equipped, and a number of services proposed in the TH plan were

rendered as a part of standard ICU care, the final operational cost narrowed down to 325 USD for

the entire treatment, excluding consultation cost. This is far less than one day admission cost of

the ICU.

Afterward, I embarked on training and development of the nursing staff. Three

educational sessions were conducted to prepare the nurses for the required clinical care (n=30).

The first session invited CNI and shift in-charges of the ICU (n=8), who were identified to

become clinical champions of TH. The session was delivered via Skype through real time

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communication. Power point presentation, discussion, case based reflection, skills demonstration,

and ECG simulator were used as teaching methodologies. Skills certification on operation of

cooling device, rectal temperature monitoring, QT analysis, and arrhythmia interpretation was

handled on site by CNI. To assess the learning of student, summative evaluation was conducted

through post-test (Refer Appendix E). Average post test score of 92% compared to pretest result

of 22.9% was appreciating (Refer Appendix F). Course evaluation was also conducted using likert

scale of 1-5 (1= poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). 87% of the participants

rated the course as excellent and 12.5% scored it very good (Refer Appendix G). Second and third

sessions were conducted onsite by CNI with the assistance of identified champions under my

supervision through Skype. Subsequently, trained nurses would undergo clinical certification on

at least one patient. Additionally, the protocol was also disseminated to the members of CPR and

ICU committee, ICU consultants and residents.

Involvement of clinical and administrative leaders in a TH task force; use of evidence

based recommendations; utilization of policy framework to guide practice; development of

clinical champions; economic operationalization of the project; and mechanisms of outcome

analysis, all these interventions are geared to sustain the program.

Findings

To date, TH has been successfully implemented on one patient and the clinical result has

been appreciating. To evaluate the overall outcome of the pilot project, survival outcomes of all

inductees would be assessed at discharge and at 6 months through physical evaluation and

telephonic follow ups respectively. Thereafter, statistical analysis would be pursuit with the help

of statistician. The survival outcome at discharge would be measured using logistic regression. To

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eliminate the influence of potential confounder or effect modifier on association between TH and

the outcome, adjusted multi-variate logistic regression analysis would also be performed,

controlling for covariates like duration of CPR, initial rhythm, blood glucose level, arterial

oxygen level, and mean arterial pressure, gender, age and acuity level. Additionally, survival

outcome at 6 months would be determined using cox regression analysis adjusted for above listed

variables.

Neurological outcome, which is operationalized by using Pittsburgh Cerebral Performance

Category (CPC) tool, would be analyzed through chi-square. The tool is valid and reliable to

measure the phenomena of interest in post CA cases; is easy to administer on site and over the

phone; and is most frequently used in post CA studies (Tiainen et al., 2007). The above

mentioned findings would also be studied using post hoc stratified analysis to examine the

difference of the outcomes based on shockable and non-shockable rhythm. We also intent to

measure secondary outcomes like length of stay in hospital and cost of care, which would then be

compared with retrospective cases of CA.

Discussion

Therapeutic effects of hypothermia post CA is convincing, but is more pronounced in

patients with shockable rhythm post OHCA. Of 10 studies reviewed, none of the RCTs have

examined the outcome benefit of TH in in-patient CA victims. Only three observational and one

quasi experimental study included both in and OHCA case. Of those, Prior et al’s. (2010) study

revealed statistically significant mortality and neurological benefit and Pfeifer et al’s. (2011)

study showed substantial neurological advantage but only in case of shockable rhythm. Limited

body of knowledge and lower level of evidences supporting the use of TH in non-shockable

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rhythm and in-hospital CA may provoke skepticism and doubts about the benefit of hypothermia

in this group, as both these cohorts may have different acuity level and may respond differently to

post resuscitation care. Thus, there was a concern raised during planning phase as if the evidences

are adequate to support the ethical premises of the project or if ethical approval is warranted for

pilot project. Richardson (2010) guides to the solution of the problem. According to her, the body

of knowledge might be limited or incomplete related to several practice concerns. She suggests

that in such scenario, CNS’s should utilize interventions recommended by expert panel, while

more rigorous research data is available to guide practice. To seek validation, the Hospital’s

Ethics Review Board was also consulted, who also denied the need for ethical approval. However,

we did incorporate informed consent by next of kin as guided by hospital’s consent policy.

Cost implication always surface as a barrier when translating evidences generated from

developed countries to the resource poor health care systems. In most of the studies reviewed, TH

is introduced and controlled through sophisticated auto-regulating cooling system like Arctic-Sun.

Disposable pads of this cooling system alone costs more than total operational cost proposed in

the plan. Similarly, esophageal temperature monitoring system, though not a heavy budget item

was disregarded as an unplanned request in the middle of a fiscal year. Blue and Fisher (2010)

assert that CNS can positively influence health care economy through critical review of

equipment acquired for the patient care. Thus, instead of Arctic-Sun device, I proposed relatively

cost efficient, locally made K-thermia cooling system for temperature maintenance, which is

being used for both cooling and warming purposes for several years in the ICU. The alternate

cooling methodologies are supported by systematic review of Walters et al. (2011), who conclude

that automated cooling systems are not absolute necessity and TH can still be achieved using

conventional cooling measures like chilled intravenous fluid, ice bags and other surface cool

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blankets. Likewise, alternate to esophageal temperature we incorporated rectal temperature

monitoring that is already available in the ICU. This modification was in lieu of Lefrant et al’s.

(2007), who suggest that rectal temperature, though not as precise as esophageal temperature, but

is more reliable than axillary probes to monitor core body temperature.

Change process is often time consuming and exhilarating. The utilization of CAS

theoretical framework invites CNS to critically analyze the situation, organize them and plan

proactively to increase the odds of success while introducing innovation. This framework, if

operationalized in its true sense, has potential to articulate and enhance major key competencies

of CNS like consultation, system leadership, researcher, moral agent, coaching, and collaboration.

(The National CNS Competency Task Force, 2008)

Conclusion

This project will mark a beginning for several events at AKUH. The pilot project has not

only introduced the novel evidence based intervention for post CA patients, but has also

ameliorated the outcome monitoring system of resuscitation service at AKUH. In next one year

time, this pilot project would hopefully produce substantial data to support replication in other

unit and in other hospitals of Karachi. In addition, this initiative is one of its kinds to support the

notion of having masters prepared CNSs in the institution to promote the culture of evidence

based nursing practice.

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References

Blue, L.,& Fisher, M. L. (2010). Economic and financial considerations for clinical nurse

specialists. In J. F. Fulton., B. L. Lyon.,& K. A. Goudreau (Eds.), Foundations of Clinical

nurse specialist (pp. 276-283). Saunders: Elsevier

Chapman, K. (2010). Using Complex adaptive systems theory to guide change. In J. F. Fulton., B.

L. Lyon.,& K. A. Goudreau (Eds.), Foundations of Clinical nurse specialist (pp. 99-111).

Richardson, J. (2010). Designing innovative interventions. In J. F. Fulton., B. L. Lyon.,& K. A.

Goudreau (Eds.), Foundations of Clinical nurse specialist (pp. 75-86). Saunders: Elsevier

Beddingfield, E., & Clark, A. P. (2012). Therapeutic hypothermia after cardiac arrest: Improving

adherence to national guidelines. Clinical Nurse Specialist CNS, 26(1), 12-18.

doi:10.1097/NUR.0b013e31823f8a02

Bernard, S. A., Gray, T. W., Buist, M. D., Jones, B. M., Silvester, W., Gutteridge, G., & Smith,

K. (2002). Treatment of comatose survivors of out-of-hospital cardiac arrest with induced

hypothermia. The New England Journal of Medicine, 346(8), 557-563.

doi:10.1056/NEJMoa003289

Burns, N., & Grove, S. K. (2009). The practice of nursing research : Appraisal, synthesis, and

generation of evidence (6th ed.). St. Louis, Mo.: Saunders/Elsevier.

Cour, M., Loufouat, J., Paillard, M., Augeul, L., Goudable, J., Ovize, M., & Argaud, L. (2011).

Inhibition of mitochondrial permeability transition to prevent the post-cardiac arrest

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syndrome: A pre-clinical study. European Heart Journal, 32(2), 226-235.

doi:10.1093/eurheartj/ehq112

Girotra, S., Nallamothu, B. K., Spertus, J. A., Li, Y.,& Chan, P. S. for the American Heart

Association Get with the Guidelines-Resuscitation Investigators. (2012). Trends in survival

outcomes after in-hospital cardiac arrest. The New England Journal of Medicine, 367(20),

1912-1920. doi:10.1056/NEJMoa1109148.

Granja, C., Ferreira, P., Ribeiro, O., & Pina, J. (2011). Improved survival with therapeutic

hypothermia after cardiac arrest with cold saline and surfacing cooling: Keep it simple.

Emergency Medicine International, 2011, 395813. doi: 10.1155/2011/395813

Hypothermia after Cardiac Arrest Study Group (HACA). (2002). Mild therapeutic hypothermia to

improve the neurologic outcome after cardiac arrest. The New England Journal of Medicine,

346(8), 549-556. doi:10.1056/NEJMoa012689

Kim, F., Olsufka, M., Longstreth, W. T.,Jr, Maynard, C., Carlbom, D., Deem, S., . . . Cobb, L. A.

(2007). Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-

hospital cardiac arrest patients with a rapid infusion of 4 degrees C normal saline.

Circulation, 115(24), 3064-3070. doi: 10.1161/CIRCULATIONAHA.106.655480

Lefrant, J. Y., Muller, L., Coussaye, J. E., Benbabaali, M., Lebris, C., Zeitoun, N., Mari, C.,&

Eledjam, J. J. (2007). Temperature measurement in intensive care patients: comparison of

urinary bladder, esophageal, rectal, axillary, and inguinal methods versus pulmonary artery

core method. Intensive Care Medicine, 29, 414-418. Doi: 10.1007/s00134-002-1619-5

SCHOLARLY PAPER 16

Neumar, R. W., Nolan, J. P., Adrie, C., Aibiki, M., Berg, R. A., Bottiger, B. W., . . . Vanden

Hoek, T. (2008). Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment,

and prognostication. A consensus statement from the international liaison committee on

resuscitation (american heart association, australian and new zealand council on

resuscitation, european resuscitation council, heart and stroke foundation of canada,

InterAmerican heart foundation, resuscitation council of asia, and the resuscitation council of

southern africa); the american heart association emergency cardiovascular care committee;

the council on cardiovascular surgery and anesthesia; the council on cardiopulmonary,

perioperative, and critical care; the council on clinical cardiology; and the stroke council.

Circulation, 118(23), 2452-2483. doi:10.1161/CIRCULATIONAHA.108.190652

Nolan, J. P., Morley, P. T., Vanden Hoek, T. L., Hickey, R. W., Kloeck, W. G., Billi, J., . . .

International Liaison Committee on Resuscitation. (2003). Therapeutic hypothermia after

cardiac arrest: An advisory statement by the advanced life support task force of the

international liaison committee on resuscitation. Circulation, 108(1), 118-121.

doi:10.1161/01.CIR.0000079019.02601.90

Nolan, J. P., Neumar, R. W., Adrie, C., Aibiki, M., Berg, R. A., Bbttiger, B. W., . . . Council on

Stroke. (2010). Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and

prognostication: A scientific statement from the international liaison committee on

resuscitation; the american heart association emergency cardiovascular care committee; the

council on cardiovascular surgery and anesthesia; the council on cardiopulmonary,

perioperative, and critical care; the council on clinical cardiology; the council on stroke (part

II). International Emergency Nursing, 18(1), 8-28. doi:10.1016/j.ienj.2009.07.001

SCHOLARLY PAPER 17

Pfeifer, R., Jung, C., Purle, S., Lauten, A., Yilmaz, A., Surber, R., . . . Figulla, H. R. (2011).

Survival does not improve when therapeutic hypothermia is added to post-cardiac arrest care.

Resuscitation, 82(9), 1168-1173. doi: 10.1016/j.resuscitation.2011.05.024

Prior, J., Lawhon-Triano, M., Fedor, D., Vanston, V. J., Getts, R., & Smego, R. A.,Jr. (2010).

Community-based application of mild therapeutic hypothermia for survivors of cardiac

arrest. Southern Medical Journal, 103(4), 295-300. doi: 10.1097/SMJ.0b013e3181d3cedb

Reinikainen, M., Oksanen, T., Leppanen, P., Torppa, T., Niskanen, M., Kurola, J., & Finnish

Intensive Care Consortium. (2012). Mortality in out-of-hospital cardiac arrest patients has

decreased in the era of therapeutic hypothermia. Acta Anaesthesiologica Scandinavica, 56(1),

110-115. doi: 10.1111/j.1399-6576.2011.02543.x; 10.1111/j.1399-6576.2011.02543.x

Storm, C., Nee, J., Roser, M., Jorres, A., & Hasper, D. (2012). Mild hypothermia treatment in

patients resuscitated from non-shockable cardiac arrest. Emergency Medicine Journal : EMJ,

29(2), 100-103. doi: 10.1136/emj.2010.105171

Stub, D., Bernard, S., Duffy, S. J., & Kaye, D. M. (2011). Post cardiac arrest syndrome: A review

of therapeutic strategies. Circulation, 123(13), 1428-1435.

doi:10.1161/CIRCULATIONAHA.110.988725

Stub, D., Hengel, C., Chan, W., Jackson, D., Sanders, K., Dart, A. M., . . . Kaye, D. M. (2011).

Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital

cardiac arrest. The American Journal of Cardiology, 107(4), 522-527. doi:

10.1016/j.amjcard.2010.10.011

SCHOLARLY PAPER 18

Testori, C., Sterz, F., Behringer, W., Haugk, M., Uray, T., Zeiner, A., . . . Losert, H. (2011). Mild

therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest

with non-shockable rhythms. Resuscitation, 82(9), 1162-1167. doi:

10.1016/j.resuscitation.2011.05.022

The National CNS Competency Task Force. (2008). Clinical nurse specialist core competencies:

Executive summary. Retrieved from

http://www.nacns.org/docs/CNSCoreCompetenciesBroch.pdf

Tiainen, M., Poutiainen, E., Kovala, T., Takkunen, O., Happola, O., & Roine, R. O. (2007).

Cognitive and neurophysiological outcome of cardiac arrest survivors treated with

therapeutic hypothermia. Stroke; a Journal of Cerebral Circulation, 38(8), 2303-2308. doi:

10.1161/STROKEAHA.107.483867

Walters, J. H., Morley, P. T.,& Nolan, J. P. (2011). The role of hypothermia in post-cardiac arrest

patients with return of spontaneous circulation: A systemic review. Resuscitation, 82, 508-

516. doi: 10.1016/j.resuscitation.2011.01.021.

van der Wal, G., Brinkman, S., Bisschops, L. L., Hoedemaekers, C. W., van der Hoeven, J. G., de

Lange, D. W., . . . Pickkers, P. (2011). Influence of mild therapeutic hypothermia after

cardiac arrest on hospital mortality. Critical Care Medicine, 39(1), 84-88. doi:

10.1097/CCM.0b013e3181fd6aef

Appendix A

Summary of Evidences

1st

Author

Study design

/Control/LOE

Sample

TH vs NT

Type of CA rhythm

Site of CA

Cooling device

Induction time from

ROSC

Target temp in TH

group /Mean temp

Cooling duration

Mean temp in

NT group

Survival Outcome

TH vs NT

Neurological Outcome

TH vs NT

Tiainen (2007)

Randomized prospective

trial(I B)

N = 70TH = 36NT= 34

Shockable *OHCA External device

NA 32-34C/33+1C

24hrsMean NA

^NTMean NA

[SO] ( 28 vs 22, p = 0.226) 93% vs 78%, no P valueCognitive outcome:

Intact or subtle deficit67% vs 44%, NS

Kim (2007)

Randomized controlled

trial(I C)

N = 97TH = 49NT = 48

All rhythms

*OHCA SC and CS

NA 32-34C/Mean NA

NA ×NTMean NA

[SO] VF group: 66% vs 45%, p= NS

Non VF group:6% vs 20%, p = NS

Adjusted OR for survival = 0.91, 95% CI=0.28 to 2.96

Awakening in VF patients:

69% vs 45%, P = 0.15Awakening in Non-VF

patients:9% vs 23%, P = 0.13

Granja (2011)

Before and after(II B)

N = 130TH = 55NT =75

All rhythms

IN and **OHCA

SC and CS

4+2.25hrs 32-34C/Mean NA

15.1+4.1hrs

×NTMean NA

[SO] 60% vs 39% ,P= 0.16 26 vs 21 patients, NS

Reinikainen 2012

Retrospective observational

with HC(III B)

N = 3958TH = 3072NT = 886

Shockable OHCANA

NA NA 32-34C/Mean NA

NA ×NTMean NA

[M]51.1% vs 57.9%, P< 0.001Adjusted OR = 0.54, 95 % CI=

0.45-0.64, P < 0.001)

NA

Prior(2010)

Retrospective cohort with

HC(III B-/C)

N = 456TH = 44NT = 368

All rhythms

IN and **OHCA

SC 2.8hrs (0.2-7.8

32-34C/Mean NA

9-28hrs ×NTMean NA

[SO] Within TH group:Shockable vs non shockable

61% vs 24%, P < 0.05

43% vs 13%, P < 0.001

Pfeifer(2011)

Retrospective observational

with HC(III B)

N = 210TH = 143NT = 67

All rhythms

IN and **OHCA

SC and CS

4-6hrs 32-34C/33+1C

24hrsMean NA

^NTMean NA

[SO] All patients:48.2% vs 44.8%, P = 0.659

For shockable :26.4% vs 28.6%, P = 0.807

For non-shockable:70.4% vs 56.4%, P = 0.149)

Better in VF patient within TH group (p < 0.001)

APPENDIX

Testori,(2011)

Retrospective cohort with

HC(III B)

N = 374TH =135NT= 239

Non Shockable

*OHCA SC and CS

1.4hrs 32-34C/33+1C

24hrsMean NA

^^NTMean NA

[SO] Adjusted OR = 0.56, 95% CI, 0.34 – 0.93

Adjusted OR = 1.84, 95% CI, 1.08 – 3.13

Storm (2012)

Prospective observational

with HC(III B)

N = 175TH = 87NT = 88

Non Shockable

IN and **OHCA

SC and CS

NA 32-34C/Mean NA

24hrsMean NA

×NTMean NA

[SO] Adjusted HR 0.98, 95% CI = 0.53-1.5, p = 0.63

27.5% vs 18.2%, P = 0.175

Stub (2011)

Retrospective observational

with HC(III B)

N = 125TH = 81NT = 44

Shockable **OHCA SC and CS

NA 32-34C/Mean NA

NA ×NTMean NA

[SO] 64% vs 39%, p <0.01Unadjusted Odds ratio 2.7,

95% CI = 1.1 – 6.4 , P = 0.02

57% vs 29%, p < 0.01

Van der (2011)

Retrospective observational

with HC(III B)

N = 5317TH= 3770NT = 1547

All rhythms

**OHCA NA NA 33-36.4C NA ^^NTMean NA

[M] 65% vs 72%, p = NAAdjust OR= 0.8, 95% CI= 0.65

– 0.98, p = 0.29

NA

LOE= Level of evidence; CA=Cardiac arrest; ROSC=Return of spontaneous circulation; SO=Survival Outcome; M=Mortality Outcome; All rhythms= VT/VF/PEA/Asystole; TH=Therapeutic hypothermia; Shockable =VT/VF; Non Shockable=PEA/Asystole; NT=Normothermia; ^ hyperthermia controlled; ^^ hyperthermia not controlled; × hyperthermia information NA; *OHCA=Out of hospital cardiac arrest(witnessed); **OHCA=Out of hospital cardiac arrest(witnessed and un witnessed);IN=In-hospital; NS=Not significant; NA=Not available/assessed; SC=Surface cooling; CS=cold saline/fluids; R=hazard ratio; HC=Historical control

Appendix B

Policy Title: Therapeutic hypothermia in adult post cardiac arrest patients

I. POLICY STATEMENT

The policy provides guidelines for the use of therapeutic hypothermia in adult patients who have sustained cardiopulmonary resuscitation with a return of spontaneous circulation (ROSC).

II. PURPOSE

The purpose of therapeutic hypothermia is to minimize post cardiac arrest brain injury in order to improve neurological and survival outcomes of post cardiac arrest patients.

III. APPLICABILE TO

a) The policy applies to patients arriving in ICU through ER or in-patient units who sustained witnessed or un-witnessed cardiopulmonary arrest and meet inclusion and exclusion criteria for therapeutic hypothermia.

b) Therapeutic hypothermia should not be initiated in uncontrolled settings like general ward, special care unit or emergency department.

IV. DEFINITIONS

a) Therapeutic hypothermia: Is a controlled lowering of patient’s core temperature to 32C – 34C ( 33C).

b) Core temperature: Represents temperature of internal visceral organs. Typical measurement sites are rectal, pulmonary artery catheter (PAC), esophageal and bladder.

c) Peripheral temperature: Sources of peripheral temperature monitoring include oral and axillary routes. They can be used to estimate core temperature with a consideration that peripheral temperature reading may lag behind core temperature changes.

d) Rewarming: Is a passive return of body temperature to 36C.

V. INDICATIONS

a) Inclusion criteria:i. Adult patients (over age of 18years) whose initial cardiac arrest rhythm is Ventricular

Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT). Patients who had Pulseless Electrical Activity (PEA) and Asystolic arrest may also benefit from the therapeutic hypothermia and should be considered for the therapy.

ii. ROSC following CPR within 60 minutes of collapse. iii. Persistent coma following ROSC. It is defined as inability to follow commands which

is not attributed to pre-cardiac arrest medical condition.

Appendix B

b) Exclusion criteria:i. Shock that is refractory to vasopressors, is a relative contraindication to therapeutic

hypothermia. ii. Patients with terminal illness or multi-organ dysfunction.

iii. Therapeutic hypothermia should not be offered to patients with following clinical manifestations. Persistent life threatening arrhythmias post ROSC Pregnancy Time laps of more than 12 hours from ROSC Pregnancy (All female patients of child bearing age must be checked for urine

hCG) Primary coagulopathy or uncontrolled bleeding. Patients with DNR. Patients with no flow time more than 60 minutes Patient with traumatic brain injury

Note: Patients who have received thrombolytic agents or who are on antiplatelet/anticoagulant therapy as deemed necessary to treat a primary cardiac condition, is not a contraindication to cooling.

VI. RESPONSIBILITY

a) ICU Medical/Anesthesia team

i. ICU intensivist/resident would determine the appropriateness of therapeutic hypothermia use for an individual patient against the set inclusion and exclusion criteria at the time of ICU admission.

ii. ICU intensivist/ ICU resident would communicate primary team and patient’s family members about the purpose of the treatment and would obtain written consent from the family.

iii. ICU intensivist/ ICU resident would ensure that the base line clinical assessment is done; ECG is reviewed for QT interval and arrhythmia; and required lab investigations are followed.

iv. ICU resident would prescribe the written order for therapeutic hypothermia, cold normal saline /ringers lactate infusion, sedation and muscle relaxant as indicated.

v. ICU resident would insert arterial and central line for monitoring.vi. ICU intensivist/ ICU resident would perform reassessment and manage complications

associated with therapeutic hypothermia.

b) ICU Nursing Team

Appendix B

i. ICU head nurse (HN) /clinical nurse instructor (CNI)/team leader would determine at the time of booking if patient is a potential candidate for therapeutic hypothermia, would inform ICU resident and would expedite the transfer process.

ii. Nurses who have attended unit specific training on therapeutic hypothermia will be responsible to implement the protocol in conjunction with head nurse/clinical nurses instructor/team leader and ICU consultant/resident.

iii. Assigned nurse would ensure that assessment time lines and monitoring recommendations are followed during pre-indication, induction, maintenance and rewarming phase.

iv. Assigned nurse would ensure that documentation is done as per defined frequency.

c) CPR Committee

i. CPR committee chair/co-chair in coordination with ICU medical director, nurse manager/ CNS would be responsible to oversee the quality assurance issues related to therapeutic hypothermia, monitor neurological and survival outcomes of patients and present trends to the leadership.

VII. PROCEDURE

a) General guidelines

i. The patient must be intubated, mechanically ventilated and on continuous cardiac monitoring.

ii. Cooling should be initiated as soon as possible, preferably within 4-6 hours of ROSC.iii. Patient should be cooled as soon as possible to achieve the target temperature of 32C –

34C ( 33C) within 4-6 hours of initiation of initiating cooling measures. iv. Target temperature should be maintained for 24 hours, with time beginning once patient

reaches the goal temperature. v. To optimize the positive outcomes of the hypothermia take measures to maintain MAP

65-100mmHg; urine output > 0.5 ml/kg; CVP 8-12 mmHg; PaO2 between 80-100mmHg,O2 saturation 94%-96%; control hyperglycemia following target blood sugar between 110-140 mg/dl.

b) Pre induction phase

i. Establish most appropriate method for continuous temperature monitoring that is rectal, bladder, esophageal or pulmonary artery catheter (PAC). Peripheral temperature should only be used as secondary source to verify temperature and should not be used to guide the therapy.

ii. Assess and document patient’s baseline neurological status, vital signs and CVP reading.

iii. Obtain base line lab for blood sugar, serum electrolyte, arterial blood gas, coagulation profile and serum lactate.

iv. Obtain rhythm strip to determine baseline QT interval and assessment of arrhythmias.

Appendix B

v. Ensure that central line is inserted for volume status monitoring and arterial line is available for blood pressure monitoring and sampling. However, induction of therapeutic hypothermia should not be delayed if the lines are not in place. Note: Arterial line access may be more difficult to obtain due to vasoconstriction, once the target temperature is reached.

vi. ETCO2 monitoring may be used to monitor variation in PCO2 during the treatment.

c) Initiation/Induction phase

i. Administer chilled (cooled at approximately 4C) Normal Saline or Ringers Lactate that is equal to 30ml/kg over 30 minutes through a peripheral line, after obtaining physician’s order.

ii. Assess for evidence of pulmonary edema before, during and after administration of fluid.

iii. Avoid using internal jugular or subclavian CVP lines to infuse cold infusion. However, femoral CVP can be used for the same.

iv. Initiate surface cooling device (K-thermia) with the goal temperature set on the machine to prevent over cooling. Ensure that water level in K-thermia is filled and device is operated as per manufacturer’s recommendation.

v. Apply ice packs to the neck, torso, armpits, flanks and groin. This method can be used in conjunction with other cooling measures to facilitate the induction process and to attain the goal temperature in a recommended time period.

vi. During this phase, continuously monitor patient’s temperature, blood pressure, heart rate and O2 saturations and document every 15 minutes in therapeutic hypothermia monitoring form (Form is in process of development)

vii. Monitor CVP and urine output every hour. viii. Assess patient for shivering every hour using Bed Side Shivering Assessment Scale

(BSAS). Notify physician if score is more than 0. Use non-pharmacological measures like socks or stocking on the feet and hands.

BSASSCORE

DEFINITION

0None

No shivering noted on palpation of the masseter, neck or chest wall and absence of ECG artifacts.

1Mild

Shivering localized to neck and/or thorax only. May only be noticed on palpation of or by the presence of ECG artifact.

2Moderate

Shivering involves gross muscle movement of upper extremities in addition to neck and thorax .

3Severe

Shivering involves gross movement of the trunk and upper and lower extremities

Appendix B

ix. Patient should be administered opioids analgesia (fentanyl, morphine sulphate) and hypnotics (propofol) or benzodiazepine (midazolam) to prevent shivering.

x. If shivering occurs despite optimal sedation, neuromuscular blocking agent (pancuronium, vecuronium, atracurium) as a bolus or infusion should be considered. Beware that the duration of action of neuromuscular blocking agent is prolong during hypothermia.

xi. In case of refractory shivering Magnesium Sulphate may be considered. xii. Train of Four must be used for patient receiving neuromuscular blockade to prevent

under or over dosing of paralytic agent (recommended blockade is 2 out of 4 twitches).xiii. Assess patient’s skin integrity every 2 hourly. xiv. Monitor and document the temperature reading of the K-thermia every hourly

d) Maintenance phase

i. Once the target temperature 32C – 34C (33 C) is achieved, hold cooling measures except for K-thermia.

ii. Maintain temperature 32C – 34C (33 C) for 24 hours, with time beginning once patient reached the goal temperature.

iii. If the temperature rises above 34C during this phase, ice packs may be reapplied to bring temperature to the required range.

iv. K-thermia must be stopped if the temperature falls below recommendation range.v. Continuously monitor patient’s temperature, blood pressure, heart rate, and O2 sats at

least every 30 minutes. vi. Pulse oximetry, commonly monitored in the digits, can be inaccurate and unreliable due

to vasoconstriction. Thus, an alternate sources like forehead sensor, or ear probe should be used.

vii. Monitor CVP and urine output every hour as per ICU protocol.viii. Check placement of rectal temperature probe every 2 – 4 hourly and verify the

temperature through secondary temperature source.ix. Check skin integrity every 2 hourly.x. Assess for shivering at least 2 hourly and PRN during the maintenance phase by using

BSAS. Notify physician if the score is more than 0. Manage shivering as described in the induction phase.

xi. Continue to document temperature reading on the K-thermia every hourly. xii. Monitor patient for following adverse effects during this phase.

xi-a) Bradycardia: often results with cooling process and is usually refractory to atropine. Intervention may not be needed unless it is associated with hemodynamic instability. xi-b) QT prolongation: QT should be monitored and documented every 4 hourly during this phase. If corrected QTc is greater than 500ms or 0.5sec, the physician should be notified immediately, as it may cause Torsades de pointes. Caution: If treatment is aborted due to persistent arrhythmia, rapid rewarming must be avoided. Patient should be rewarmed following the rewarming guidelines.

Appendix B

xi- c) Hyperglycemia: hypothermia decreases insulin sensitivity and secretion and causes hyperglycemia. Monitor blood glucose every 2-4 hourly as per patient’s baseline or ICU protocol. If hyperglycemia develops, monitor blood glucose every hourly and initiate insulin therapy as per physician’s order. Note: Due to peripheral vasoconstriction, capillary glucose measurements during hypothermia can be inaccurate. Therefore, it is advised to obtain blood glucose levels using arterial or central line and verify with lab glucose value prior to insulin treatment. xi-d) Electrolyte imbalances: Hypokalemia, hypomagnesemia, hypocalcemia, and hypophosphatemia can occur during cooling phase due to intracellular shift of electrolytes. Check electrolyte every 6-8 hourly or as ordered. Note: Electrolyte shift reverses when the patient is rewarmed. xi-e) Coagulopathies: may occur with hypothermia. Ensure that patient is monitored for signs of bleeding. Apply adequate pressure if new arterial or venipuncture is performed during cooling phase. Check coagulation profile every 12 hour or as ordered. Platelet and coagulation correction would be at the discretion of ICU physician. xi-f) Volume depletion: Hypothermia induced diuresis may occur causing volume depletion. Monitor and document CVP and urine output every hourly along with other hemodynamic parameter. Maintain adequate hydration as per physician order.

e) Rewarming phase i. Rewarming phase begins upon completion of 24 hours of maintenance phase.

ii. ICU consultant/ resident must be notified when rewarming is initiated. iii. Turn off all cooling measure and let the patient rewarm passively to a temperature of

36C. Remove wet sheets and apply blankets, socks and stocking to facilitate warming process.

iv. Passive rewarming may take 8-12 hour. Temperature rise should not be faster than 0.25 - 0.5 C per hour.

v. Monitor patient’s temperature, blood pressure, heart rate, and O2 sats and document every 30 minutes.

vi. Use of K-thermia or bair hugger should only be reserved if temperature does not rise as per recommendation in initial 6 hours of rewarming phase. Ensure that rewarming does not exceed 0.5 C per hour if any of these devices are used.

vii. Monitor and document the temperature readings of K-thermia/Bair Hugger every hourly if it is used to facilitate rewarming.

viii. K-thermia/Bair Hugger and all other measures must be stopped once patient’s temperature reaches 36C.

ix. Closely monitor patient for following adverse effects during this phase.ix-a) Hypotension: Vasodilation during rewarming phase may cause hypotension. Administered fluid as per physician’s order to keep MAP above 60mmHg. ix-b) Hyperkalemia: Monitor patient for signs of hyperkalemia that may occur due to extracellular shift of electrolyte.

x. Sedation and/or neuromuscular blocking agent (if started earlier) should be maintained till temperature of 36C is achieved. Thereafter, sedation and muscle relaxant can be stopped upon discretion of ICU physician.

xi. Efforts must be made to prevent pyrexia (38C) during initial 72 hours from the time of cardiac arrest.

Appendix B

References.

References are already list under the assignment section. Developed By: Roshan Jan Muhammad

Appendix C

The Aga Khan University HospitalDivision of Nursing Services

Therapeutic hypothermia monitoring sheet

Date of cardiac arrest: ____________________Time of cardiac arrest: ____________________Duration of code: ________________________Time of return of ROSC: ___________________Location of cardiac arrest: Out of hospital In-hospital ______Witnessed: Yes NoInitial Rhythm Requiring Chest Compressions: PEA Asystole Ventricular Tachycardia Torsades de pointes Ventricular Fibrillation

Pre therapeutic hypothermia checks

Consent __________ Primary team notified__________GCS: E___M___V___.Pupils (Size and reaction)R________ L _________ECG rhythm:____________________ QT interval: ____Sr. K _______ Sr. Mg _______Sr. Ca ________Sr. Lactate__________Blood sugar __________CVP_______________ MAP________________CPC Score at discharge_________ 6 months ________

Therapeutic Hypothermia SummaryInduction time ______ Time target temperature achieved___Duration of maintenance phase: ___________Duration of rewarming phase: ____________

Time38.037.537.036.536.035.034.534.033.833.633.433.233.032.832.632.432.232.031.0S PO2SBPDBPMAPCVPReflo

Appendix C

QT

Shivering Assessment TimeShivering scoreMeasures taken

Cooling Techniques TimeCold NS/RLIce packsK-thermia (Temp)Time38.037.537.036.536.035.034.534.033.833.633.433.233.032.832.632.432.232.031.0S PO2SBPDBPMAPCVPQT

Shivering Assessment TimeShivering scoreMeasures taken

Key for measures taken: SB (sedation bolus) SII(Sedation infusion incremented), MB(Muscle relaxant bolus), MgSO4, NPM (Non-pharmacological measures)Cooling Techniques

Time

Appendix C

Cold NS/RLIce packsK-thermia (Temp)

Lab Investigations Date/TimeBlood SugarPotassiumCalciumMagnesiumPhosphatePlateletPT/INRAPTT

Note: The image and the format of the form has distorted during transfer of content

Appendix D

Budget for therapeutic hypothermia service per patient

Capital Cost

Brand Equipment No of units

required

Cost per unit ($)

Total cost

Already available in the ICU

Philips Rectal temperature probes

1 300.00 300.00 Yes

K-thermia

Cooling device 1

2500.00 2500.00 Yes

Grasbey Infusion pump 1 2000.00 2000.00 YesOperational Cost

Lab investigations TotalFrequency

cost perfrequency

($)

Total cost Part of standard ICU

Care- Serum Lactate 2 8 16 Yes- CBC 4 10 40 Once per day is

standard of care in ICU- Basic metabolic panel +

Mg and phosphate4 25 100 Twice per day is

standard of care in ICU- Coagulation profile

(PT/APTT/INR)4 10 40 Once per day is

standard of care in ICU- Blood sugar (Finger

stick)12 1 12 Six per day is standard

of care in ICU- ECG 2 10 20 Once per day is

standard of care in ICUMedications Quantity Cost per

unitTotal cost

Part of standard ICU Care

- Normal Saline drips (1 Liter)

1 5 5 Yes

- Sedation/muscle relaxant variable variable 200 VariableMonitoring services Quantity Cost per

unitTotal cost

Part of standard ICU Care

Arrow Arterial line 1 76 76 Standard of care in ICU

BD CVP line (triple lumen) 1 45 45 Standard of care in ICU

BD Pressure transducer system for arterial line and CVP monitoring

1 150 150 Standard of care in ICU

- Arterial line and CVP insertion cost

1 100 100 Standard of care in ICU

Total Operational cost = 804Total Operational Cost Excluding Standard ICU Care Elements = 325

.

OthersService Total

Hourscharges per hour

total charges

- Telephonic consultation of CNS and training hours

20 hours 40 dollars per hour

800 No

Note: The capital cost is proposed to offer hypothermia treatment to 2 patients at any given time. Depreciation and recovery elements are not incorporated which are part of detailed financial feasibility report otherwise. For the project, no new items were needed to be purchased as the required items were already available. Operational item list is not exhaustive. Total cost of USD 804 incudes services that are part of routine ICU care regardless of therapeutic hypothermia intervention, therefore, numbers should be interpreted carefully as they are projected for future reference if the service replication is intended in future to the other units.

Appendix E

Therapeutic Hypothermia Training Pre and Post Test

1. It is a Class I recommendation of the American Heart Association (AHA) to induce therapeutic hypothermia in adults following cardiac arrest to temperatures of

a) 86.0°F (30°C) to 89.6°F (32°C)b) 87.8°F (31°C) to 91.4°F (33°C)c) 89.6°F (32°C) to 93.2°F (34°C)d) 91.4°F (33°C) to 95.0°F (35°C)

2. This Class I recommendation of the AHA includes maintaining therapeutic hypothermia for how many hours?

a) 2 to 4b) 4 to 8 c) 8 to 12d) 12 to 24

3. Induced hypothermia is contraindicated in patients who have a) intracranial hemorrhage.b) myocardial infarction. c) atrial fibrillation.d) diabetes mellitus.

4. During the induction stage, acceptable invasive methods include rapidly infusing lactated Ringer’s solution that has been cooled to

a) 37.4°F (3°C)b) 39.2°F (4°C)c) 41.0°F (5°C)d) 42.8°F (6°C)

5. Which of the following invasive lines cannot be used to infused cold saline or Ringers Lactate

a) Peripheral linesb) Central Venous catheter in femoral veinc) Central venous catheter in jugular veind) None of the above

6. Which of the following is not a preferred means of monitoring the temperature of a patient undergoing therapeutic hypothermia is with which type of thermometer.

a) Axillary b) Esophageal c) Rectal d) Bladder

7. Patient undergoing therapeutic hypothermia are typically rewarmed over how many hours?

APPENDIX E

a) 8-12 hours b) 4-6 hoursc) 6-8 hours d) 12-24 hours

8. Therapeutic hypothermia is most beneficial if it is introduced within _________time of return of spontaneous circulation.

a) 4-6 hoursb) 6-12 hours c) 12-24 hours d) > 24 hours

9. Which of the following are the side effects during maintenance phase of therapeutic hypothermia. (Select all that applies)

a) Bleeding b) QT prolongationc) Hypomagnesemia d) Hyperkalemia e) Bradycardiaf) Tachycardiag) Hypotensionh) Hyperglycemiai) Shiveringj) Diuresis

10. Which particular rhythm disturbance is most likely to develop during maintenance phase of therapeutic hypothermia

a) Atrial fibrillation b) Bradycardiac) Junctional tachycardiad) Ventricular fibrillation

11. Which of the following are not candidates for therapeutic hypothermia. (Select all that applies)

a) Persistent life threatening arrhythmias post ROSCb) Pregnancyc) Time laps of more than 12 hours from ROSCd) Primary coagulopathy or uncontrolled bleeding. e) Patients with no flow time less than 60 minutesf) Patient with traumatic brain injury

12. Which of the following is the side effects during rewarming phase of therapeutic hypothermia. (Select all applicable)

a) Bleeding

APPENDIX E

b) QT prolongationc) Hypomagnesemia d) Hyperkalemia e) Bradycardiaf) Hypotension

13. Patient undergoing therapeutic hypothermia are typically rewarmed not more thana) 0.25 C per hour. b) 0.25 - 0.5 C per hour c) 0.5 - 0.75 C per hour. d) 0.75 – 1.0 C per hour.

14. Bedside nurse palpates the patient and notices shivering that is localized to neck and/or thorax along with presence of ECG artifact. How would you rate the shivering using bedside shivering scale.

a) Grade 0 b) Grade I (Mild)c) Grade II (Moderate)d) Grade III (Severe)

15. Which of the following is considered shivering prophylaxis for hypothermia patientsa) Opioids analgesia, hypnotics or benzodiazepineb) Opioids analgesia, neuromuscular blocking agent c) Neuromuscular blocking agent, Magnesium sulphated) Opioids analgesia, Magnesium Sulphate

Appendix F

Pre and Post test Comparison

Questions Pre test Post testIt is a Class I recommendation of the American Heart Association (AHA) to induce therapeutic hypothermia in adults following cardiac arrest to temperatures of

25 100

This Class I recommendation of the AHA includes maintaining therapeu¬tic hypothermia for how many hours?

12.5 100

Induced hypothermia is contraindicated in patients who have 25 87 During the induction stage, acceptable invasive methods include rapidly infusing lactated Ringer’s solution that has been cooled to

0 100

Which of the following invasive lines cannot be used to infused cold saline or Ringers Lactate

50 87

Which of the following is not a preferred means of monitoring the temperature of a patient undergoing therapeutic hypothermia is with which type of thermometer

37 87

Patient undergoing therapeutic hypothermia are typically rewarmed over how many hours?

25 75

Therapeutic hypothermia is most beneficial if it is introduced within _________time of return of spontaneous circulation.

0 100

Which particular rhythm disturbance is most likely to develop during maintenance phase of therapeutic hypothermia

37 87

Which of the following is the side effects during rewarming phase of therapeutic hypothermia. (Select all applicable)

25 100

Patient undergoing therapeutic hypothermia are typically rewarmed not more than

0 87

Bedside nurse palpates the patient and notices shivering that is localized to neck and/or thorax along with presence of ECG artifact. How would you rate the shivering using bedside shivering scale.

37 87

Which of the following is considered shivering prophylaxis for hypothermia patients

25 100

Average Score 22.96 92.07Which of the following are the side effects during maintenance phase of therapeutic hypothermia. (Select all that applies)

NA NA

Which of the following are not candidates for therapeutic hypothermia. (Select all that applies)

NA NA

Note: Last 2 questions were not included in the analysis because of multiple correct answers.

Appendix G

Course Evaluation Summary

Questions Poor Fair

Good

V.Good

Excellent

TOTAL

Language was clear and understandable 0 0 0 0 8 8Presenter was knowledgeable and confident

0 0 0 0 8 8

Presentation content was clear and understandable

0 0 0 0 8 8

Presenter was able to facilitate your learning

0 0 0 0 8 8

Various teaching methods were used 0 0 0 1 7 8Discussion was encouraged 0 0 0 1 7 8Presenter was able to hold your interest 0 0 0 0 8 8Presenter was sensitive towards individual learners' needs

0 0 0 1 7 8

Time was utilized effectively 0 0 0 0 8 8Presenter was well planned and organized 0 0 0 0 8 8Did this presentation prepare you adequately to implement therapeutic hypothermia on patient

0 0 0 3 5 8

Overall rating for the course 0 0 0 1 7 8Percentage of overall rating - - - 12.5% 87% -