Practical issues in therapeutic hypothermia

Practical issues of cooling

1. How to cool?
Arrest ROSC

temperature

2. When to start cooling?

3. How deep to cool?

Time time

4. How long to keep cool?

Our initial experiences with hypothermia

How to cool?

University of Chicago Hospitals (UCH) initial experience (2003-4): cooling blanket and/or ice packing Advantages: cheap, non-invasive, off the shelf Disadvantages: slow cooling, can be messy, lack of thermostatic control

Overcooling using ice for hypothermia

Difficulties with ice bag cooling

Merchant RM et al, 2006 Retrospective chart review of cooling cases From three hospitals (2 in U.S., 1 in U.K.) Found 20/32 cases (63%) were overcooled

Trends towards better outcome in non-overcooled pts

Suggests need for thermostatic feedback control

An example of a patient cooled with ice

Surface cooling in the real world

40 39 38

Example A

Temperature (Celsius)

37 36 35 34 33 32 31 30 29 0 4 8 12 16 Time (hours) 20 24 28 32

Merchant RM et al, 2006

What about cold intravenous fluids?

Is cold saline enough?

Cold infusions alone are effective for induction of therapeutic Hypothermia but do not keep patients cool after cardiac arrest

But maintenance was hard Kliegel et al, 2007

Cooling was fast

65% cooled to target within 60 minutes 77% failed to stay cool during course

An example from the real world of cooling patients

Real world usage: Switzerland

From evidence to clinical practice: Effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest Oddo et al, Critical Care Medicine 2006 Oddo M et al, 2006

Study at one hospital in Switzerland

Survivors of out-of-hospital arrest

Cooling initially via ice bags, then cooling mattress Target temperature 33oC, maintained for 24 hrs

A real world example: cerebral performance category (CPC) outcomes

Real world usage: Switzerland

Outcome at discharge for out-of-hospital VF arrest

baseline cooling

CPC5 56% CPC 5 40%

.CPC3

CPC3 19% CPC2 14%

CPC2 12% CPC1 42%

CPC1 14%

5%

A real world example: cerebral performance category (CPC) outcomes Real world usage: Switzerland

Outcome at discharge for out-of-hospital asystole arrest

baseline

CPC5 89%

CPC3 11%

cooling

CPC5 83%

CPC1 17%

Post-arrest care is more than just cooling

Post-arrest care is a critical care bundle: Therapeutic hypothermia

Careful blood pressure management

Treatment for coronary blockages Brain and outcomes assessment

A public resource for more hypothermia information

Hypothermia resource website

www.med.upenn.edu/resuscitation/Hypothermia.htm

Training program for health care providers

Hypothermia Training Institute at Penn Philadelphia next course March, 2013 Intensive two day CME course in hypothermia methods, protocols, and applications Designed for critical care, cardiology or emergency medicine physicians and nurse managers i.e., local champions Offers hypothermia certification Workshop design small course size held quarterly

Upcoming Coursera lectures in this program

Lecture 2: Lecture 3:

Rethinking CPR: quality of care and new ideas about training Therapeutic hypothermia and postresuscitation care Frontiers in resuscitation: reperfusion medicine and cardiac bypass Survivorship and end-of-life issues after cardiac arrest

Lecture 4: Lecture 5: