Download Hypothermia treatment protocol

Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
Contents:
1) Indications
2
2) Exclusion criteria
3
3) Essential patient resources
3
4) Optional patient resources
3
5) Nursing staffing
4
6) Patient monitoring
4
7) Endotracheal intubation and mechanical ventilation
5
8) Shiver suppression and management
5
9) Hypothermia induction and maintenance
8
10) Rewarming
9
11) Patient management issues (DVT prophylaxis, nutrition, potassium)
9
12) Modified Bedside Shiver Assessment Scale (mBSAS) and interventions
reference
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
1) Consider using hypothermia in the following:
a) Post Cardio-Pulmonary Resuscitation
i) Inclusion Criteria:
(1) Age  18 years old
(2) Cardio-Pulmonary arrest with return of spontaneous circulation (ROSC)
(3) Persistent coma as evidenced by no eye opening to pain after
resuscitation (no minimum waiting period required)
(4) Systolic Blood Pressure can be maintained > 90 mm Hg or Mean Arterial
Pressure (MAP) > 60 mmHg either spontaneously or with fluids and
low/moderate dose pressors
(5) Known time of cardiac arrest (excludes prolonged “found down”)
(6) No limit on duration of resuscitation effort; however less than 1 hour
most desirable
(7) Able to initiate therapy within 6 hours of ROSC – ideally within 1 hour
b) Acute ischemic stroke and Spontaneous Intracranial Hemorrhage
i) Inclusion criteria:
(1) Age  18 years old
(2) Moderate to severe stroke (NIH Stroke Scale score  8)
(a) And/or radiographic findings predictive for significant neurologic
impairment (i.e. large MCA stroke, lobar ICH > 30 mL, etc.)
(b) And/or radiographic indications of increased ICP (significant cerebral
edema, shift, etc.)
(3) Systolic Blood Pressure can be maintained > 90 mm Hg or Mean Arterial
Pressure (MAP) > 60 mmHg either spontaneously or with fluids and
low/moderate dose pressors (not aortic balloon pump)
(4) Able to initiate therapy within 12-24 hours of symptom onset – ideally
within 2-3 hours of symptom onset
c) Traumatic Brain Injury
i) Inclusion criteria:
(1) Age  18 years old
(2) Glasgow Coma Scale < 8
(3) Radiographic indications of increased ICP (significant cerebral edema,
shift, etc.)
(4) Systolic Blood Pressure can be maintained > 90 mm Hg or Mean Arterial
Pressure (MAP) > 60 mmHg either spontaneously or with fluids and
low/moderate dose pressors (not aortic balloon pump)
(5) Able to initiate therapy within four hours of trauma
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
d) Refractory Increased Intracranial Pressure
i) Inclusion criteria:
(1) Age  18 years old
(2) Intracranial pressure > 25 mmHg despite maximal medical therapy (if
intracranial pressure monitoring used). If ICP monitoring is not used,
follow recommendations in (3) below
(3) Clinical and/or radiographic indication(s) of significantly increased ICP
despite maximal medical therapy
(4) Systolic Blood Pressure can be maintained > 90 mm Hg or Mean Arterial
Pressure (MAP) > 60 mmHg either spontaneously or with fluids and
low/moderate dose pressors (not aortic balloon pump)
e) Refractory seizures (status epilepticus)
i) Inclusion criteria:
(1) Age  18 years old
(2) Continuous seizure activity or recurrent seizures without a return to preictal functioning
(a) In the setting of at least 2 medications [i.e. Lorazepam (Ativan) and
Phenytoin (Dilantin)]
(3) Systolic Blood Pressure can be maintained > 90 mm Hg or Mean Arterial
Pressure (MAP) > 60 mmHg either spontaneously or with fluids and
low/moderate dose pressors (not aortic balloon pump)
2) Exclusion Criteria
i) Sepsis
ii) Persistent, hemodynamically significant cardiac dysrhythmias
iii) Pregnancy (relative contraindication)
iv) Known, pre-existing clinically significant coagulopathy or bleeding
v) Pre-existing illness limiting life-expectancy to < 6 months
vi) Pre-existing significant neurological disability (modified Rankin Scale Score >
2)
vii) Patient has a known hypersensitivity to hypothermia (Raynaud’s disease,
sickle cell disease, cryoglobulinemia, etc.)
3) Essential patient resources include:
a) Standard ICU monitoring
b) Salem sump oro-gastric tube
c) Foley catheter
d) Medi-therm III Hypothermia machine with 2 sets of hoses and one set of RaprRound wraps (Torso and Legs x 2)
e) Esophageal temperature probe
f) BIS monitor
4) Optional patient resources include:
a) CVP or PA catheter (preferably positioned in the Subclavian Vein) is optional but
recommended (if needed, may initiate therapy before central line placed)
b) Arterial pressure line (if needed, may initiate therapy before arterial line placed)
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
5) Nursing staffing: Therapeutic mild hypothermia does not require a 1:1 assignment,
however, during therapy induction (1-2 hours) the patient will require a 1:1 nurse
with no other assignment during this period. Nurses caring for patients undergoing
therapeutic hypothermia must not have an assignment of more than 1:2
6) Patient monitoring
a) Continuous and record hourly
i) Cardiac monitor
ii) Oxygen saturation
iii) BIS monitor
iv) Shiver assessment
b) Every 15 minutes, record until the patient has reached target 330 C (91.40 F),
then hourly
i) Core Temperature
ii) Blood pressure
c) Every 1 hours
i) Initiate IV insulin protocol
d) Baseline diagnostics and labs (therapy may start before the lab results are
available)
i) 12 lead ECG
ii) Portable CXR
iii) Arterial blood gases
iv) CBC with diff
v) PT/INR/aPTT
vi) CMP, Magnesium and Phosphorus
vii) Lactate
viii) Cardiac profile
ix) Urinalysis (culture if indicated)
a) Every 6 hours
i) BMP
ii) Magnesium
iii) Cardiac profile
b) Every 24 hours
i) Portable chest X-Ray (if indicated)
ii) Arterial blood gases
iii) CBC with diff
iv) PT/INR/aPTT
v) CMP, Magnesium and Phosphorus
vi) Lactate
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
2) Endotracheal intubation and mechanical ventilation
a) Endotracheal intubation and mechanical ventilation is usually needed to induce
therapeutic hypothermia with surface cooling techniques. However, this therapy
may be attempted without mechanical ventilation in selected cases. If the
patient is intubated:
i) Assure and maintain appropriate endotracheal tube placement per standard
protocol
ii) Ventilator setting as appropriate for the patient’s presenting condition(s)
3) Shiver suppression and management
a) Induction of shivering suppression protocol
i) Shiver is a MAJOR clinical issue with therapeutic hypothermia. Each patient
should be observed closely for shiver. In addition to visual monitoring, the
nurse should gently palpate the patient’s masseters (jaw), pectoralis, and
deltoids every 30 to 60 minutes. In addition, fine fluctuations on the
patient’s cardiac rhythm tracing as well as an unexplained/sudden increase in
BIS values or fine fluctuations in the BIS tracing may also indicate shiver.
ii) Shiver suppression should be based on the modified Bedside Shivering
Assessment Scale (mBSAS). Assess and record the patient’s mBSAS every 30
– 60 minutes and prn. Palpate the following muscle groups – masseters
(jaw), pectoralis, deltoids, and quadriceps.
0 – No shiver
1 – MILD = shivering localized to the neck and/or thorax; or fine
artifact on cardiac rhythm; or fine artifact on BIS tracing; or
unexplained, significant increase in BIS value
2 – MODERATE = shivering involves gross movement of the upper
extremities (in addition to neck and thorax)
3 – SEVERE = shivering involves gross movements of the trunk
and upper and lower extremities
(1) Interventions for shiver suppression should be step-wise and based on
the mBSAS
0 – No Shiver
Optimize sedation and analgesia
Dexmedetomidine (Precedex) or Propofol
(Diprivan) infusion
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Vasodilatation
Magnesium drip
1 – MILD
Continue
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
Optimize sedation and analgesia
Dexmedetomidine (Precedex) or Propofol
(Diprivan) infusion
Fentanyl infusion
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Vasodilatation
Magnesium drip
Add
Meperidine (Demerol) 12.5 mg IV bolus dose
2 – MODERATE
Continue same interventions as with score of 1 above and
increase Meperidine (Demerol) to 25 mg IV bolus
dose
3 – SEVERE
Optimize sedation and analgesia
Dexmedetomidine (Precedex) or Propofol
(Diprivan) infusion
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Meperidine (Demerol) IV bolus
Vasodilatation
Magnesium drip
Add
Neuromuscular blockade
Vecuronium (Norcuron) intermittent
boluses
iii) Specific instructions for shiver suppression/management
(1) Initiation of therapy
(a) Lorazepam (Ativan) only use lorazepam bolus if the patient is
not already adequately sedated at the initiation of therapy
(i) Bolus 4 mg IV push x 1 over 2 minutes
(2) Maintenance of therapy (should be maintained till the patient has been
returned to a core temperature of 360 C
(a) Continuous sedation
(i) Patients undergoing therapeutic hypothermia must be adequately
sedated. The clinician should select either Dexmedetomidine
(Precedex) or Propofol (Diprivan) based on the clinical situation
(ii) Dexmedetomidine (Precedex) is associated with a lower incidence
of induced delirium, however, the bradycardic side-effects of this
agent may limit it’s suitability in selected patients. Consider using
Propofol (Diprivan) in patients with persistent bradycardia below
35 bpm
(iii) Dexmedetomidine (Precedex) (to provide shiver suppression
and continuous sedation)
1. Bolus 1 mcg/kg over 10 minutes, then
2. Continuous infusion at 0.2 – 1.5 mcg/kg/hour
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
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(b)
(c)
(d)
(e)
(f)
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3. Maintain BIS reading of 40 - 60
(iv) Propofol (Diprivan) (to provide shiver suppression and
continuous sedation)
1. Continuous infusion at 20 mcg/kg/min
2. Titrate by 5-10 mcg/kg/min every 10 minutes
3. Maintain BIS reading of 40 – 60
Vecuronium (Norcuron) (only AFTER adequate sedation achieved)
(i) Bolus 0.1 mg/kg x 1 at therapy initiation, and
(ii) Re-bolus Vecuronium 0.1 mg/kg prn shivering (mBSAS = 3)
(iii) Do not use continuous infusion
Fentanyl (adjunctive therapy for shiver suppression and sedation)
(i) Bolus 50 mcg IV push and repeat every 30 minutes until the
continuous infusion is initiated
(ii) Continuous infusion at 2 – 5 mcg/kg/hour
Buspirone (BusPar) [(pharmacologically lowers the shiver
threshold, and this effect is synergistic with Dexmedetomidine
(Precedex) and propofol (Diprivan)]
(i) Initial dose 30 mg by gastric tube then,
(ii) 15 mg by gastric tube every 8 hours until rewarmed to 360 C
Magnesium drip (vasodilatation – improves efficacy of cooling and
increases patient comfort)
(i) Prepare 12 grams Magnesium Sulfate in 250 mL of normal saline
(ii) Continuous infusion at 10 mL/hr
(iii) Titrate to maintain a serum magnesium level of 3 – 4 mg/dL
(iv) Monitor serum magnesium levels every 6 hours
Meperidine (Demerol) (pharmacologically lowers the shiver
threshold and is synergistic with buspirone)
(i) 25 mg IV bolus x 1 prn initially, then
(ii) 12.5 mg IV bolus every 30 minutes PRN mild shiver (mBSAS 1)
(iii) 25 mg IV bolus every 30 minutes PRN moderate shiver (mBSAS 2)
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4) Hypothermia induction, maintenance and rewarming – see below
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


Hypothermia induction and maintenance
Place esophageal continuous temperature probe
Turn on the machine and fill the wraps with water before placing on the
patient
Torso wrap and leg wraps
o Apply Torso wrap directly on the patient
Therapy induction
o If initial core temperature > 34.50 C – use cold saline infusion
 Infuse cold NS (kept in medication refrigerator)
 1000 mL x 2 over 10 minutes each (use a pressure
bag)
o After initial boluses, give an additional volume
of cold saline to make a final volume of 40
mL/kg
o If core temperature reaches 340 C, discontinue
cold NS infusion
o Connect the temperature probe to the Medi-therm III Cooling
Machine and set on AUTO – RAPID Mode and the Set-Point = 330
C
o If initial core temperature < 34.50 C – do not use cold saline
infusion. Proceed with initiation as above and follow therapy
maintenance protocol below
Therapy maintenance
o If the core temperature is at anytime below 310 C
 Immediately initiate active warming until the core
temperature returns to 330 C
 Remove cloth blankets and gown
 Open torso wrap and leg wraps (but do not remove)
 Place warm air blanket on patient and set at 400 C
 Once the core temperature is > 320 C
 Remove warm air blanket
 Reapply torso and leg wraps
 Restart cooling with the Cooling Machine AUTO
setting at 330 C
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
5) Rewarming – the goal is to actively, but in a controlled and gradual fashion, rewarm
the patient to a normal temperature over 24 hours, and maintain a normal
temperature for at least 24 additional hours
a) Set the machine on AUTO / GRADUAL with set-point 370 C. This setting will
rewarm at a rate of 0.170 C per hour
b) Once the patient’s core temperature reaches 360 C
i) Discontinue Vecuronium (Norcuron) and buspirone (BusPar)
ii) Discontinue analgosedation (Precedex/Propofol and Ativan) unless otherwise
required for ongoing patient management (no longer required for therapeutic
hypothermia)
c) Continue to monitor and record core temperature every hour until the patient’s
core temperature remains less than or equal to 37.50 C x 24 hours
d) If the patient has a core temperature above 37.50 C
i) Immediately initiate normothermia protocol
6) Patient management issues
a) DVT prophylaxis
i) Foot pumps
(1) If the patient is fully anticoagulated (INR > 2 or aPTT > 60) do not use
foot pumps during therapeutic hypothermia
(2) If the patient is not anticoagulated (INR < 2 or aPTT < 60)
(a) apply foot pumps
(b) administer Lovenox 30 mg or 40 mg subcutaneously daily unless
contraindicated
b) Nutrition
i) May attempt enteral feedings only if the patient’s head can be continuously
maintained at or greater than 300
ii) Closely monitor gastric residuals every 2 hours and hold enteral feedings for
residuals > 200 ml and restart feedings when residuals are < 100 ml
iii) May use gastric motility agents (i.e. metoclopramide [Reglan]) if indicated
c) Serum Potassium
i) Serum hypokalemia occurs with hypothermia as the potassium moves into
the cells. When the patient is re-warmed, the patient’s serum potassium will
increase. Aggressive potassium supplementation during hypothermia may
result in hyperkalemia when the patient is re-warmed
ii) Do not provide potassium supplementation unless:
(1) The serum potassium is less than 3.0 mmol/L or
(2) Potassium associated cardiac instability
iii) If potassium supplementation is provided:
(1) Target serum potassium level is 3.5 mmol/L or
(2) Until potassium associated cardiac instability is corrected
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Protocol for Therapeutic Hypothermia with Rapr-Round Wraps
Medi-Therm III MTA 7900
Modified Bedside Shiver Assessment Scale (mBSAS)
0 – No shiver
1 – MILD = shivering localized to the neck and/or thorax; or fine
artifact on cardiac rhythm; or fine artifact on BIS tracing; or
unexplained, significant increase in BIS value
2 – MODERATE = shivering involves gross movement of the
upper extremities (in addition to neck and thorax)
3 – SEVERE = shivering involves gross movements of the trunk and
upper and lower extremities
Interventions based on mBSAS
0 – No Shiver
Optimize sedation and analgesia
Propofol (Diprivan) drip
Fentanyl drip
Alter shiver threshold
Buspirone (BusPar) by gastric tube
Vasodilatation
Magnesium drip
1 – MILD – all interventions above and ADD
Alter shiver threshold
Meperidine (Demerol) 12.5 mg IV bolus
2 – MODERATE – all interventions in number 1 above
Increase Meperidine (Demerol) to 25 mg IV bolus
3 – SEVERE – all interventions above and ADD
Neuromuscular blockade
Vecuronium (Norcuron) intermittent boluses
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