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THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARREST USING PERFORMANCE TARGETS

THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARREST USING PERFORMANCE TARGETS. Raghu Loganathan, MD, FCCP Director, Medical ICU & Stroke Center March 2010. Disclosures. Nothing extraordinary in the case reports Use 2 case studies to describe successful implementation of a new protocol.

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THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARREST USING PERFORMANCE TARGETS

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  1. THERAPEUTIC HYPOTHERMIA FOR CARDIAC ARRESTUSING PERFORMANCE TARGETS Raghu Loganathan, MD, FCCP Director, Medical ICU & Stroke Center March 2010

  2. Disclosures • Nothing extraordinary in the case reports • Use 2 case studies to describe successful implementation of a new protocol

  3. Out of Hospital cardiac arrests 64% of all arrests 2 to 9% survive to discharge 1/ 3rd of survivors have irreversible cognitive dysfunction In-hospital cardiac arrests 36 % of all arrests 18% survive to discharge Cardiac Arrest Epidemiology ILCOR 2008 Circulation 2008; 118:2452-83

  4. MILD THERAPUETIC HYPOTHERMIACLINCIAL STUDIES • RCT’s • Bernard S et al – NEJM 2002; 346(8) • Holtzer M et al – NEJM 2002; 346 (8) • Idrissi et al – NEJM 2001 • Other Designs • Benson D et al – Anaes Analg 1959; vol 38 • Bernard S et al – Ann Emerg Med 1997; 33(2) • Bernard S et al – Resuscitation 2003; 56(1) • Meta-analysis • Holtzer M et al – Crit Care Med 2005; 33(2)

  5. Summary of Landmark Trials HACA study group, NEJM, 2002 & Bernard SA, NEJM 2002

  6. MILD THERAPEUTIC HYPOTHERMIAFDNY initiative • Less than 15% hospitals are currently using hypothermia in US • Designated hypothermia centers • Cardiac arrests triaged by EMS • Model based on STEMI/ PCI centers & Stroke Centers

  7. Case Study -1 • 69 year old male progressively dyspenic for 5 days • EMS found him cyanotic • Initial PEA, followed by asystole and V fib • Intubated on the field • Downtime 26 minutes PMH: HTN, COPD, CAD, Morbid Obesity • Arrived in ED comatose, GCS 3T • PAP 54 on ventilator

  8. Case Study -1 • Cold saline: 4.5 liters started within 5 minutes • Surface cooling in 25 minutes • Central line placed 30 minutes • Initial Lactate was 9.3, ScVo2 65% • Baseline Temp was 37.2 • Target temp reached in 3.4 hours • Double vests used in series

  9. Case Study -1 • EKG: no STEMI • Mild elevation of troponins • ECHO showed depressed EF (30%) with wall motion abnormalities • CXR showed lower lobe infiltrates

  10. Case Study -1 • Posturing with de-cerebrating signs noted at 5 hours • TH continued with sedation and paralytics for shivering • Re-warming after 24 hours • EEG showed diffuse slowing, no seizures • No clinical response when sedation was stopped • Day 3; spontaneous eye opening and followed some commands • Day 6 Able to follow more commands

  11. Case Study -1 • Day 9: Unable to extubate transferred to vent floor • Day 17 Trach done • Day 23 weaned off Trach • Day 25 discharged to SNF • March 25th: Trach de-cannulated, ambulating and functioning at baseline

  12. Case Study : 2 • 72 year old male well known to Lincoln BIBEMS • ESRD, Known asthma, Known CAD • EMS called for respiratory distress, “noted to hypotensive and dyspneic and went into cardiac arrest” • “Wide QRS on 3 lead” placed on NRB • Subsequently “patient agonal, PEA on monitor, 3 blocks from hospital, CPR started immediately” • ED arrival 10 minutes later: CPR continued • Intubated in ED, various rhythms, 2 doses of epinephrine and atropine given

  13. Case Study : 2 • Post intubation, noted to be “de-cerebrating” by ED attending • ROSC at 25 minutes:BP 143/ 76, RR 20 at set rate and Pulse 67 • MICU called for therapeutic hypothermia • Unresponsive to deep stimuli, comatose • Hypothermia initiated 40 mins after ROSC • Myoclonic jerks observed day 1 • 36 hours into protocol: patient opens eyes and following simple commands

  14. Who to Cool?Inclusion Criteria • Post-cardiac arrest: defined as absence of pulses requiring chest compressions, regardless of location or presenting rhythm • Any Initial rhythm (VF/VT, asystole or PEA) • ROSC within 30 minutes to a SBP > 90 mmHg (with or without vasoactive meds) • Patient is comatose (unable to follow commands/ GCS < 6) upon arrival to the hospital in the absence of sedation • Time at start of cooling is within 4 hours after ROSC

  15. Who to Cool?Exclusion Criteria • Another reason to be comatose • Purposeful response to verbal commands or noxious stimuli after ROSC and prior to initiation of hypothermia • Absent brainstem function not explained by treatment with sedatives, paralytics or anti-cholinergic agents • A known terminal illness preceding arrest • ? Pregnancy ( Case report showing benefit)

  16. Who to Cool?Exclusion Criteria • Pre-existing DNR and / or DNI code status and patient not intubated as part of resuscitation efforts • Multi-organ system failure, refractory shock requiring high doses of vasopressors (MAP<60 on 2 or more vasopressor agents), severe persistent hypoxia, acidosis or co-morbidities with minimal chance of meaningful survival independent of neurological status • Uncontrolled bleeding to coagulopathy • Recurrent VF or refractory VT in spite of appropriate therapy should generate consideration of emergent referral for cardiac catheterization          

  17. Aa Typical Cooling and Rewarming Protocol Aa

  18. How to Cool?ICU Notification • Once eligibility for induced hypothermia is determined, call MICU/ Stroke attending ASAP • Obtain 2 large bore IV lines • Obtain baseline temperature • Infusion of approximately 2 to 3 liters (for 70 kg individual) of normal saline refrigerated at 4-5 °C • Can safely and reliably lower core body temperature by 3-4 °C when infused over 50 minutes.

  19. COOLING PROTOCOL • Obtain laboratory tests ASAP: • Beta HCG on all women of childbearing age • Arterial blood gas • CBC/ platelets / PT / PTT/INR, Fibrinogen • Electrolyte “panel 7”, plus iCa / Mg / Phos , Cl-, Glucose • Amylase, Lipase, LFTs, , Lactate, CPK-MB, CK, Troponin • Blood Cultures, Urine Cultures, Urinalysis • Toxicology screen if appropriate • 12 lead EKG, Chest X-ray • Placement of urinary catheter with temperature sensor • Insertion of Central Line Catheter (subclavian or IJ)

  20. GAYMAR III Not selling this product

  21. January 2009 to February 2010 58 cardiac arrest patients to ED 22 patients in ED with ROSC 18 INPATIENTS screened 14 PATIENTS COOLED 12 INPATIENTS COOLED

  22. Clinical Characteristics • 26 patients cooled • Rhythm: • Vtach/ Vfib = 3 patients • Asystole/ PEA = 18 • Mixed (VF with asystole/ PEA) = 5 patients • Average APACHE II = 26 (predicted death rate of 64%) • 22/ 26 had 100% compliance with hypothermia bundle • Average ICU days on vent 7.03 days

  23. OUTCOMES • 26 patients cooled • 11/ 26 (42.3%) survived to hospital discharge • 10/ 26 (38.4%) had “good outcomes”

  24. OUTCOMES BY RHYTHM

  25. Summary of Studies Neurologic 50%vs 14% Neurologic 23%vs7% Survival 50%vs 23% Survival 54%vs 33% Neurologic 49%vs26% Neurologic 55%vs39% Survival 48%vs 32% Survival 59%vs 45%

  26. Who to Cool ? Does Rhythm Matter? • Data from RCTs” • Suggest VF and VT • Combination of rhythms during a cardiac arrest event • Underlying mechanisms of brain injury are same • Multiple observational trials on asystolic rhythm have shown benefit

  27. Who to cool? Do Circumstances of Arrest Adequately Predict Outcome? Practice Parameters: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation, NEUROLOGY 2006;67:203–210

  28. Complications HACA study group, NEJM, 2002

  29. SUMMARY • Screening of patients: • Judgement improves with time • Rhythm alone should not exclude patients • Most have combined rhythms • Information on initial rhythm not always available • Use of bundles helps with rapid implementation and achieving target temp • Performance targets helps

  30. FUTURE DIRECTIONS • Phase 2 FDNY hypothermia • Cool Enroute to hospital • MCA ischemic Infarcts • Traumatic brain injury • SAH patients with increased ICP • Hepatic encephalopathy

  31. Old CPR

  32. HYPOTHERMIA

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