Download I - University of Pennsylvania

HUP
Clinical Practice
Policy/Procedure
KEYWORDS:
Cooling
REFER TO:
HUP Policy 1-12-22 Pain
Assessment
CCC-05-05 Use of Bispectral
Index (BIS) Monitoring
4A-03-22 Eye Care
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 1 of 9
INTRODUCTION
Patients undergoing post-cardiac arrest resuscitation (PCAR) and
targeted temperature management (TTM) will have nursing care
provided according to the following policy.
SCOPE
Registered Nurses (RNs) working in the Emergency Department (ED)
and adult Critical Care Units in which use of the PCAR and TTM are
approved by the Medical Director.
ELIGIBILITY CRITERIA
A.
4A-02-05a Electronic
Documentation of Medication
Administration
Patient post-cardiac arrest: defined as absence of pulses
requiring chest compressions, regardless of location or
presenting rhythm with subsequent return of spontaneous
circulation (ROSC).
B.
BCC-03-26 Neuromuscular
Blocking Agent
Less than 12 hours have elapsed since ROSC (Return of
Spontaneous Circulation).
C.
Patient does not have an order for Do Not Attempt Resuscitation
(DNR) B or C; or a Do Not Intubate (DNI).
D.
Patient’s pre-arrest cognitive status is not severely impaired
(Glasgow Coma Score [GCS] =15 or performed ADL
HUP Formulary
Center for Resuscitation
Science website for Nursing
Quick Sheet
independently).
E.
Patient is comatose at enrollment with a Glasgow Motor Score <6 (doesn’t follow commands)
pre-sedation.
F.
No other obvious reasons for coma.
G.
No uncontrolled bleeding.
H.
No evidence of uncontrollable dysrhythmias.
I.
No pre-existing multi-organ dysfunction syndrome, severe sepsis, or metabolic acidosis as a
cause of arrest.
J.
No comorbidities with minimal chance of meaningful survival independent of neurological status.
BACKGROUND
Brain temperature during the first 24 hours after resuscitation from cardiac arrest may have a significant
effect on survival and neurological recovery. Cooling to 32-34°C for 24 hours decreases the chance of
death and increases the chance of neurological recovery.
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 2 of 9
EFFECTS OF TARGETED TEMPERATURE MANAGEMENT
A.
Hypothermia activates the sympathetic nervous system causing vasoconstriction and shivering.
Shivering increases O2 consumption by 40-100%. Thus, shivering must be prevented during
hypothermia and is best accomplished by initiating neuromuscular paralysis prior to induction of
hypothermia.
Note: If paralysis is begun well after TTM has been initiated it can result in a precipitous drop in
core body temperature. Elderly patients will cool more quickly than younger or obese patients.
B.
Hypothermia shifts the oxyhemoglobin curve to the left and may result in decreased O 2 delivery.
However, the metabolic rate is also lowered, decreasing O2 consumption and carbon dioxide
(CO2) production. Ventilator settings may need to be adjusted due to decreased CO 2 production,
using blood gases.
C.
Hypothermia initially causes sinus tachycardia, then bradycardia.
1.
2.
Extremely important to keep temperature >30ºC.
Temperatures:
a.
b.
3.
<30º C, increased risk for arrhythmias.
<28º C, increased risk for ventricular fibrillation.
Severely hypothermic myocardium (<30°C) is less responsive to defibrillation and
medications.
D.
Hypothermia decreases cardiac output and increases systemic vascular resistance (SVR).
E.
Hypothermia can induce an in vivo coagulopathy which is not detectable by laboratory testing (as
blood is warmed during testing).
F.
Hypothermia-induced diuresis is to be expected and should be treated aggressively with fluid and
electrolyte repletion. Magnesium, phosphorus and potassium should be monitored closely and
maintained in the normal range (because it will rebound to a higher value during rewarming).
G.
Decreased insulin secretion and sensitivity leads to hyperglycemia, which should be treated
aggressively.
H.
Re-warming too rapidly can cause vasodilation, hypotension, and rapid electrolyte shifts.
I.
Monitor blood sugar prior to rewarming. Monitor for hypoglycemia during the rewarming phase.
J.
Re-warming is begun 24 hours from the time target temperature is reached.
K.
Maintain active normothermia for 48 hours after 37°C obtained.
PROCEDURE
HUP
Hospital of the University of Pennsylvania
NURSING
Clinical Practice
Policy/Procedure
A.
5.
Explain the purpose of TTM and the need for pharmacologic paralysis.
Encourage the family to continue to talk to the patient.
Provide emotional support and answer any questions.
Offer pastoral care support to the family. Facilitate communication between the family
and the physicians, nurse practitioners (NP), and physician’s assistants (PA).
Neuroprognostication should not occur until 72 hours after rewarming.
Gather Equipment for Cooling.
1.
2.
3.
4.
Two one liter bags of cold (4ºC) 0.9% saline (stored in participating units’ medication
refrigerators).
PreSep catheter and tubing set up.
Arterial catheter and tubing set up.
Gaymar III 7900 (Blue-faced) external cooling system (available on participating units)
with two complete sets of hoses.
a.
b.
c.
d.
One Gaymar torso wrap.
Two thigh cooling leg wraps (available through Gaymar company).
Choose small-medium or large wraps depending on patient size for the most
effective cooling.
Weight of Gaymar wraps when filled:
1.)
2.)
3.)
5.
6.
7.
b.
8.
9.
Large Torso: 3.0 lbs
Medium/Small Torso: 2.5 lbs
Each Leg: 2.0 lbs
Temperature probe indwelling bladder catheter. (Bard Temperature Sensing Foley 400
Series - product #90911616– no minimum urine output required for use)
1/4-1/8” adapter for cooling device (stored with the Gaymar III).
Neuromuscular blockade equipment (not required for ED).
a.
C.
Page 3 of 9
Provide Patient and Family Education Support.
1.
2.
3.
4.
B.
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Peripheral nerve stimulator. (Refer to BCC-03-26 Neuromuscular Blocking
Agent) Use TTM TOF policy for titration.
Consider BIS monitor and sensor for monitoring sedation depth. (Refer to CCC05-05 Use of Bispectral Index (BIS) Monitoring)
Ensure fluid warmer is available for IVF in case need arises after cooling.
Note: Please document in the Comment section of Sunrise: time/date TTM initiated,
target temperature reached, rewarming initiated, normothermia reached. If TTM is
initiated in the Emergency Department please document time/date TH was initiated in the
ED during RN report.
Preparation for Cooling:
1.
Verify prescriber’s orders (SCM Post-Cardiac Arrest/Targeted Temperature Management
Order set)
HUP
Clinical Practice
Policy/Procedure
2.
3.
4.
5.
6.
7.
D.
Hospital of the University of Pennsylvania
NURSING
BCC-04-05
Nursing Practice
Manual
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
Page 4 of 9
Notify Resuscitation Consult Team: 267-253-9035
Ensure arterial catheter is inserted BEFORE or SIMULTANEOUS with initiation of
cooling, as it is difficult to place once the patient is cooled. Central venous access (CVC)
is not required immediately, providing the patient is hemodynamically stable and has
good peripheral access; however, it should be placed expeditiously to guide post-arrest
resuscitation. Although any CVC is acceptable, use of the PreSEP triple lumen catheter
is ideal for continuous venous oximetry monitoring.
Obtain baseline labs per prescriber’s order:

ABG with Ionized Ca+ and Magnesium

CBC, Platelets, PT/PTT/INR, Fibrinogen

Electrolyte “panel 7”, phosphate, chloride, glucose

Amylase, lipase

Liver function panel

Lactate, CPK-MB, CK, Troponin

Cortisol level (if indicated)

Pan-culture: Blood Culture, Urine culture, Urinalysis, Sputum culture (if
appropriate)

Toxicology screen (if appropriate)

Co-oximetry on a Central Venous blood sample

Beta HCG on all women of childbearing age
Place temperature probe indwelling bladder catheter (Bard Temperature Sensing Foley
400 Series - product #90911616 – no minimum urine output required for use). If bladder
monitoring is not an option or temperature reading inaccurate, consider an alternative
site, i.e. esophageal probe (CDR # 100158). NOTE: If bladder pressure is being
performed, it is recommended that an esophageal probe be used for temperature
monitoring.
Thorough skin assessment before applying cooling system wraps. Check skin, especially
under the wraps, q 4 hours.
Note: Please document in the Comment section of Sunrise: time/date TTM initiated,
target temperature reached. If TTM is initiated in the Emergency Department please
document time/date TH was initiated in the ED during RN report.
Cooling
1.
Infuse intravenous (IV) fluids as per hypothermia protocol as needed.
a.
2.
Cold saline (4ºC) (up to 2 liters) may be used to facilitate cooling.
Administer medications per prescriber’s orders. (Refer to 4A-02-05a Electronic
Documentation of Medication Administration)
a.
b.
Ensure adequate sedation using RASS initially. Following paralysis, BIS
monitoring (with goal of 40-60) may be used to titrate sedatives.
Initiate neuromuscular blockade before cooling (pancuronium is recommended
unless there is concomitant renal or hepatic insufficiency; in which case
cisatracurium should be used; Cisatracurium can be used if patients have renal
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 5 of 9
insufficiency defined as a creatinine clearance <10 ml/min and/or hepatic
insufficiency defined as total bilirubin >3mg/dl associated with liver disease or
dysfunction (Refer to HUP Formulary). Use TTM TOF policy for titration.
*If patient temperature is ≤ 34ºC on presentation, maintain temperature at 3234ºC with cooling blanket. Maintain paralysis until after rewarming is complete
(36⁰C). Ensure adequate paralysis by using peripheral nerve stimulator (Refer to
BCC-03-26 Neuromuscular Blocking Agent). Use TTM TOF policy for titration.
E.
3.
Gaymar Cooling Device:
If using BLUE-faced Gaymar III set to Automatic mode, set point 33º Rapid mode, for
24 hours from time target temperature reached.
If using GRAY-faced Gaymar III set to Automatic mode, Rapid cooling, set point 34ºC.
Once the patient reaches 34ºC set to Gradual mode at 33ºC.

Keep device plugged in at all times during use.

Make sure leg and chest wraps are filled before applying to the patient.

Apply circumferential torso pad and connect to first cooling hose.

Apply circumferential thigh wrap to each leg, connect leg wraps together in
series, and then connect free ends to second cooling hose.

Connect temperature probe indwelling bladder catheter to temperature
monitoring port on cooling device. Bard Temperature Sensing Foley 400 Series product #90911616– no minimum urine output required for use)

If bladder monitoring is not an option or temperature readings inaccurate,
switch to an alternative site, i.e. esophageal probe (CDR #100158),
placed by physician, nurse practitioner or physician’s assistant.

Protect indwelling bladder catheter and temperature probe from coming
in contact with cooling blanket wraps.

Check skin, especially under the cooling wraps, q 4 hours.

Ensure cooling blanket in- and out-flow tracts are unobstructed and that fluid is
filling wraps when machine is turned on. You may need to add more water to
device until plunger in tank rises to point where green line is seen.

Assess and document cooling blanket settings and patient’s temperature in °C.

Document patient temperature and blanket temperature on flowsheet in °C.
4.
Cooling is maintained for 24 hours from time target temperature is reached.
Monitoring
1.
2.
Goal is to maintain patient’s core temperature between 32° and 34°C for 24 hours from
time target temperature is reached.
Maintain blanket temp at 33°C automatic mode, follow patient temperature hourly.
a.
b.
3.
If temp < 31° C, consider infusing 250 ml boluses of warm 40°C IV NSS or LR
until temperature > 32°C.
Monitor closely for arrhythmias when temperature < 32°C.
Hemodynamic Assessment:
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 6 of 9
Continuous venous oxygen saturation (ScvO2) with PreSEP™ catheter.
Central venous oxygen saturation (ScvO2) every 6 hours and PRN if PreSEP™
catheter is not used.
c.
Maintain MAP 80-100 mm Hg, per hemodynamic algorithm, unless there are
contraindications, e.g., acute coronary syndrome, aortic aneurysm.
d. EEG must be started within 6-12 hours of TTM initiation and continued until re-warming
complete and paralytics discontinued. Call the EEG Fellow at 215-404-6771. For issues
or concerns, if you cannot get a hold of the EEG fellow, please page the Neurology on
call resident. See EEG “quick sheet” in the appendices of the TTM order set. This is for
educational purposes only.
e.
Somatosensory Evoked Potentials (SSEP): When clinically appropriate,
consider ordering on day 3 (72 hours-post-ROSC). Place order for SSEP in
Sunrise with a note that states “post-cardiac arrest”. For questions call the lab at
215-662-2661.
a.
b.
4.
Obtain laboratory values per prescriber’s orders:
a.
b.
c.
d.
e.
5.
Urine output every 2 hours and more frequently if needed.
a.
b.
c.
F.
Arterial blood gas (ABG) every 6 hours and as needed.
Glucose, potassium (K+) and lactate every 6 hours until re-warming process
complete (may require intensive glucose control and more frequent monitoring
while cooled).
Repeat Creatine phosphokinase-MB (CPK-MB), CK, Troponin every 6 hours until
re-warming process complete.
Complete blood count (CBC)/platelets/prothrombin time (PT)/partial
thromboplastin time (PTT), electrolytes/blood urea nitrogen (BUN)/Creatine,
Calcium/Magnesium/Phosphate every 6 hours until re-warming process
complete.
If continuous SvO2 catheter is not used, perform co-oximetry on Central Venous
blood samples every 1-2 hours for the first 6 hours then q 6 and/or PRN as
clinically indicated.
Hypothermia-induced diuresis is common.
Aggressive IV fluid repletion may be required.
Confirm decreased urine output with bladder scanner if acute decrease in urine
output noted.
Re-Warming
1.
2.
3.
Begin re-warming 24 hours after target temperature reached.
Re-warming too rapidly can cause vasodilatation, hypotension and rapid electrolyte
shifts.
Prior to rewarming:
a.
Volume load aggressively with Normal Saline to compensate for reductions in
BP, Scv02, and central venous pressure (CVP).
HUP
Clinical Practice
Policy/Procedure
b.
4.
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 7 of 9
K+ shifts to extracellular compartment during re-warming.

STOP all K+ containing fluids.

However, always correct hypokalemia, and other electrolytes, to the
normal range.

Check blood sugar prior to rewarming.
Re-warm gradually:
a.
b.
Maintain paralysis until patient reaches 36°C.
Rewarm patient to a temperature of 37°C.
If using BLUE-faced Gaymar III with automatic re-warming algorithm, set to
automatic mode, set point 37º Moderate mode. The moderate mode will
increase the set point automatically 0.33° every hour (~12 hours).
Note: During re-warming, do not change mode from Automatic mode to Manual.
This will re-set the re-warming algorithm and affect the re-warming time.
The Blue-faced Gaymar Medi-Therm III will re-warm the patient at the set
temperature and speed based on the mode selected and will not allow the patient
to re-warm any faster.
If using GRAY-faced Gaymar III with manual re-warming, set to manual mode
and manually increase the blanket temperature 0.33ºC every 1 hour until the
patient temperature reaches 36ºC.
5.
6.
7.
8.
Assess vital signs with CVP every 1 hour until temperature reaches 37°C.
Monitor K+ every 6 hours and more frequently if needed.
Monitor for hypoglycemia during the rewarming phase.
Monitor serum glucose levels closely because as insulin resistance resolves there is
increased risk of hypoglycemia.
9.
Note: Please document in the Comment section of Sunrise: time/date rewarming initiated
and normothermia reached.
10.
Follow ABGs as needed. Adjust ventilator settings accordingly with Respiratory Therapy
and physician/Nurse Practitioner (NP)/physician assistant (PA) collaboration.
11.
Anticipate reduction in venous return (cardiac output) and BP (with ↓CVP) as cooler
blood shifts from core to extremities. Follow CVP, ScVO2, UO and exam closely;
aggressive IV fluids may be necessary to maintain adequate volume status and perfusion
during re-warming.
12. Maintain paralysis until patient temperature > 36°C. Once temperature ≥36°C, paralysis
can be stopped, BIS monitoring (if used) should be discontinued when train of four (TOF)
is 4/4. Titrate sedation to comfort (RASS) and ventilator synchrony. (Refer to HUP
Policy 1-12-22 Pain Assessment). (See TTM specific TOF policy)When clinically
appropriate, consider SSEP on day 3 (72 hours-post-ROSC) or later. Place order for
SSEP in Sunrise with a note that states “post-cardiac arrest” or for questions call the lab
at 215-662-2661.
13. Neuroprognostication should not take place until at least 72 hours after rewarming.
HUP
Hospital of the University of Pennsylvania
NURSING
Clinical Practice
Policy/Procedure
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 8 of 9
14. Maintain active normothermia for 48 hours: keep cooling wraps on the patient for 48
hours after rewarming and administer acetaminophen around the clock for the same 48
hour time period. Monitor skin breakdown closely during this time.
15. Note: Acetaminophen should not be administered in patients with fulminant hepatic
failure. Use caution in patients with chronic liver disease or acute liver injury. Consider
decreased dosing in this patient population, not to exceed 2 grams daily
DOCUMENTATION
A.
Nursing Flow sheet for Inpatient Units/Emtrac for ED patients:
Note: Please document in the Comment section of Sunrise: time/date TTM initiated, target temperature
reached, rewarming initiated, normothermia reached. If TTM is initiated in the Emergency Department
please document time/date TH was initiated in the ED during RN report.
1.
2.
Vital Signs.
Hemodynamics:
a.
b.
3.
4.
5.
6.
7.
8.
B.
Patient’s tolerance to the procedure.
Ongoing assessments.
Family updates.
Sunrise Clinical Manager (SCM): Medication Administration Record (MAR) (Refer to 4A-02-05a
Electronic Documentation of Medication Administration)
1.
2.
3.
D.
Baseline and ongoing neurological exam, pain assessment and level of
sedation/agitation.
Administration of analgesia, sedation and NMB agents.
Cooling blanket settings in °C with each change (use separate column).
Patient’s temperature in °C.
Eye care.
Skin care and repositioning.
Interdisciplinary Progress Notes:
1.
2.
3.
C.
CVP
ScvO2
Time infusion begun.
Dose administered.
Time infusion discontinued.
SCM Post-Cardiac Arrest/Targeted Temperature Management Order set.
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
Post Cardiac Arrest Targeted Temperature
Management Nursing Care
BCC-04-05
Nursing Practice
Manual
Page 9 of 9
REFERENCES
Arrich, J., Holzer, M., Herkner, H., Mullner, M. Cochrane corner: hypothermia for neuroprotection in
adults after cardiopulmonary resuscitation. Anesth Analg. 2010: 110(4): 1239.
Rossetti, A.O., Oddo, M., Logroscino, G., Kaplan, P.W. Prognostication after cardiac arrest and
hypothermia: a prospective study. Ann Neurol. 2010; 67(3): 30 107.
Hypothermia after Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic
Outcome After Cardiac Arrest. New England Journal of Medicine, 2002; 346(8):549-556.
Bernard, S.A., Gray, T.W., Buist, M.D., et al. Treatment of Comatose Survivors of Out-of-Hospital
Cardiac Arrest With Induced Hypothermia. New England Journal of Medicine, 2002; 346(8): 557-563.
Polderman, K.H. Application of Therapeutic Hypothermia in the Intensive Care Unit. Opportunities and
Pitfalls of a Promising Treatment Modality--Part 2: Practical Aspects And Side Effects. Intensive Care
Medicine, 2004; 30(5):757-69.
Zeiner, A., Holzer, M., Sterz, F., et al. Hyperthermia After Cardiac Arrest is Associated with an
Unfavorable Neurologic Outcome. Arch Intern Med, 2001;161(16): 2007-2012.
Center for Resuscitation Science: http://www.med.upenn.edu/resuscitation/hypothermia/index.shtml
REVIEWS/APPROVALS
Critical Care Practice Committee
Emergency Department Leadership
MICU Medical Director
MICU Nurse Manager
CCU Clinical Nurse Specialist
Co-Directors, Clinical Center for Resuscitation Science
Supersedes: November 30, 2007; 5/29/09
Effective Date: May 19, 2010
Updated: May 1, 2012
Updated: Sept 1, 2013
Disclaimer
Any printed copy of this policy is only as current as of the date it was printed; it may not reflect
subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited
to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside
the institution without administrative permission.