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Emergency Department/Critical Care
Management of the Patient Receiving Mild Therapeutic
Hypothermia after Cardiac Arrest
3/2010
Critical Care Committee
Emergency Department Leadership
4/2010
Joint Commission Chapter:
JCAHO Standard PC3.130
Cardiac Arrest, Hypothermia
Purpose:
The purpose of this protocol is to guide the medical and nursing staff in the appropriate
management of the patient receiving mild therapeutic hypothermia (MTH) following a
cardiac arrest.
Equipment:
Cold (4˚C) normal saline (from Trauma refrigerator)
Naso/oro gastric tube
Esophageal temperature probe
Thermometer
External cooling blankets
Endovascular cooling device
Ice packs
Towels
Background/Supportive Data:
Brain temperature during the first 24 hours after resuscitation from cardiac arrest may
have a significant effect on survival and neurological recovery. Cooling the patient to 3234 °C for 24 hours decreases the chance of death and increases the chance of
neurological recovery.
1. Review patient eligibility
a. Inclusion Criteria:
1. Age greater than 21.
2. Cardiac arrest defined as: documented pulselessness in a patient who
received cardiopulmonary resuscitation (CPR) regardless of initial
cardiac rhythm.
3. The patient has return of spontaneous circulation (ROSC).
4. Less than 6 hours since ROSC.
5. The patient is comatose at the time of cooling. (Comatose is defined
as: not following commands, no speech, no eye opening, no
purposeful movements to noxious stimuli1. Brainstem reflexes and
pathological/posturing movements are permissible. Sedative or
paralytic medications should be unnecessary during the evaluation.)
CP/IB 2008
Draft updated 4/26/2010
6. Out-of-hospital cardiac arrest: presumed cardiac etiology.
7. In-hospital cardiac arrest: unexpected ventricular fibrillation/tachycardia
cardiac arrest. For post surgical patients, discretion will be left to the
primary surgeon.
8. Negative Head CT if presumed head injury.
9. Pre-arrest cognitive status not severely impaired (ie: able to perform
ADL independently).
10. No evidence of uncontrolled dysrhythmias or untreated complete heart
block.
Exclusion Criteria:
1. Age less than or equal to 21 years.
2. Pregnancy.
3. Presumed non-cardiac cause for arrest: i.e. trauma, stroke, poisoning,
sepsis, and seizure.
5. Known severe coagulopathy history or significant active bleeding.
(Anticoagulation, antiplatelet agents, and thrombolytics [TPA] are not
contraindicated.)
6. Patient has valid Do Not Resuscitate/Intubate order.
7. Pre-existing multisystem organ failure
8. Prolonged down time is not an absolute contraindication but
resuscitation time of less than 1 hour is recommended.
2. Pre-Induction
Activate “Code Chill” by calling hospital operator
1. This will notify the ICU screener, CCU charge nurse, Neurology
resident, Nursing supervisor, Respiratory therapist, Pharmacy,
Admitting.
2. For private patients, the attending will notify requested cardiologist and
intensivist. For service patients, the ICU screener will notify the UCG
fellow and appropriate cardiologist and intensivist.
3. Patients will be admitted to the CCU.
a. Mandatory Organ Sharing Network notification within 60 minutes of arrival.
1. To facilitate early identification of potential donors, all ventilator
dependent patients (regardless of age, diagnosis, sedation or religious
beliefs) will be referred to the NJ Sharing Network by the primary
nurse.
2. Ideal referral will be within 1 hour of arrival, but no longer than two
hours of meeting the following clinical triggers: a of GCS of 5 or less, or
the loss of two or more of the following reflexes: gag, cough, pupils,
corneal, respiration, or response to pain.
b. Mandatory Critical Care Consult with initiation of hypothermia.
c. Mandatory Neurology consult within 12 hours to help facilitate EEG
monitoring for seizure activity during cooling.
d. Establish and secure an airway.
1. Maintain the patient on mechanical ventilation without warm humidified
oxygen.
2. Maintain PaO2 of 100 mmHg and a PaCO2 of 40 mmHg.
e. Obtain a stat 12-lead EKG.
1. Analyze electrocardiogram (EKG).
CP/IB 2008
Draft updated 4/26/2010
If the EKG is suggestive of ST elevation myocardial infarction (STEMI),
proceed with current Code MI protocol. MTH may be considered, but
should not delay transport to the CATH lab. Ensure discussion with
interventional cardiologist as per Code MI protocol, but if cold fluid and/or
line placement are requested prior to catheterization consider placement
location.
2. If an anti-arrhythmic is needed consider administration of Amiodarone.
3. If the patient’s history and EKG are suggestive of acute coronary
syndrome without MI, administer anticoagulation as appropriate.
f. Apply continuous cardiac monitoring.
g. Apply continuous pulse oximetry.
h. Establish at least 2 large bore IVs of size 18g or greater.
i. Maintain mean arterial pressure (MAP) 80-100 mmHg to help maintain
adequate cerebral perfusion. If evidence of CHF, ACS or Shock use lower
range of MAP (80-100 mmHg) and may even require a goal MAP as low
as 65 mmHg, depending on the degree cardiac dysfunction. If patient is
showing signs of CHF/Pulmonary Edema stop fluid infusion and call MD.
1. Vasopressors, inotropes, nitrates, and fluid bolus may be used as
indicated.
2. Consider a lower MAP goal if clear CHF or acute coronary syndrome.
j. Administer appropriate pain control.
k. Administer appropriate sedation.
l. Administer appropriate neuromuscular blockade for shivering prevention.
Single initial dose of vecuronium preferred; titrate future doses to maintain
2/4 with train-of-four monitoring.
m. Insert an oral gastric tube and connect it to continuous low wall suction.
n. Administer aspirin per OGT to all patients unless contraindicated.
o. Check glucose.
1. If not known diabetic and initial glucose level was within target of 100150 mg/dl, recheck every 4 hours.
2. If known diabetic or not within target of 100-150 mg/dl, recheck every 2
hours.
3. If greater than 150 mg/dl, consider insulin bolus or drip as appropriate.
p. Draw and send appropriate labs including ABG, CMP, CBC, LFTS,
PT/INR, PTT, Type & Screen, Lactate, Cardiac enzymes.
q. Vital signs (Temperature, Pulse, Respirations, Blood Pressure and Pulse
Oximetry) should be recorded at a minimum of every 15 minutes for 2
hours, then every 30 minutes for 4 hours and hourly thereafter.
r. Notify MD for any dysrhythmia or heart rate less than 50 beats/min.
s. Insert temperature sensing Foley catheter, if unavailable or contraindicated,
the physician will insert an esophageal temperature probe.
t. Record hourly I&O.
u. Insert an A-line as soon as possible, preferably before MTH initiation. Radial
location preferred.
v. Obtain baseline temperature.
3. Hypothermia Induction
a. All Patients
1. Document time that cooling is initiated.
CP/IB 2008
Draft updated 4/26/2010
2. Infuse intravenously 1500-2000 ml of cold (4 ºC from the refrigerator)
0.9% NaCL bolus over a period of 20 minutes unless clear
contraindication of pulmonary edema. If known cardiomyopathy may
consider reduced fluid bolus.
3. Close the door to the patient’s room and set thermostat in the patient’s
room as close to 60 oF if possible.
4. Remove all clothing and apply a hospital gown.
5. Cover hands/feet in dry towel to prevent thermal injury.
6. Notify MD immediately if shivering occurs during induction. Titrate
neuromuscular blockade.
7. Monitor the patient for hypothermia-related diuresis. Consider 1:1 fluid
replacement with cold 0.9% NS or Lactated Ringers. If known
cardiomyopathy the 1:1 fluid replacement should include the current
volume of all infusions.
8. Replace electrolytes as needed. Maintain serum potassium between
3.2 and 3.5 mEq/L. Anticipate a rise in potassium as warming occurs.
b. Endovascular Cooling
1. Obtain KUB to ensure that an IVC filter is not present.
2. The MD will insert an endovascular cooling catheter via femoral site as
long as an IVC filter is not present. If immediate cardiac
catheterization is anticipated, discuss placement location with
interventional cardiologist. Consider fluoroscopy guidance if filter
present and difficulty anticipated.
3. Catheters may be inserted in the ED, ICU, and cath lab.
4. Set up endovascular cooling module according to manufacturer’s
specifications. Set goal temperature as 33.0 ºC [91.4 ºF] (for target
temperature range 33-34 ºC [91.4-93.2 ºF]) and cooling rate
“maximum.”
5. Note: ports on endovascular catheters can be used for routine central
line functions, including CVP measurement except administration of
mannitol due to temperature dependent crystallization.
6. Use caution if any catheter must be placed above the diaphragm if
baseline temperature is less than 32 °C [89.6 ˚F] due to risk of
ventricular ectopy.
c. Surface Cooling (if endovascular cooling device not available)
1. Apply cooling blanket below and above patient with sheets between
blankets and patient. Skin is NOT to come in direct contact with cooling
blankets.
2 Apply ice packs wrapped in towels to the axillae, groin, and sides of
neck.
3. Remove ice packs and stop cold saline once temperature is less than or
equal to 34 ºC [93.2 ºF].
4. Consider turning off cooling blanket temporarily to avoid temperature
overshoot.
5. Complete skin assessment at a minimum of every 2 hours.
6. During rewarming using auxiliary surface cooling, slowly discontinue
cooling blanket or consider setting water temperature in cooling blanket to 35
°C and slowly increasing the water temperature by 0.5 °C every 2 hours until
CP/IB 2008
Draft updated 4/26/2010
a stable core body temperature of 36 °C has been reached. Do not warm
faster than 0.5 °C/hour.
4. Hypothermia Maintenance
1. Record the exact time that the core temperature first reaches the target
range (less than or equal to 34 ºC [93.2 ºF]) on the nursing flow sheet.
2. Maintain core temperature 33-34 ºC [91.4-93.2 ºF] for 24 consecutive
total hours starting from initiation of cooling.
3. If temperature falls below 32.2 °C [90.0 ºF], notify MD immediately.
4. Continue 1:1 urine output replacement with cold 0.9%NS.Avoid
potassium repletion within 6 hours of anticipated rewarming as
potassium will shift back out of cells and hyperkalemia may result.
5. Nutrition therapy should be held during the initiation or maintenance
phase of therapy due to reduced metabolism and preferential shunting
of blood to other organs.
Re-warming
a. All Patients
1. After 24 hours total of hypothermia, re-warm at no more than 0.5
ºC/hour.
2. Record all vital signs at a minimum of every 30 minutes during
rewarming.
3. Set ambient room temperature to 68 ˚F degrees.
4. Maintain neuromuscular blockade until temperature reaches 36 ºC
[96.8 ˚F].
5. Potassium administration including any mixed fluids should be
stopped as potassium may increase during rewarming. Monitor
potassium every 6 hours for 24 hours post warming.
6. Notify MD once temperature returns to 36 °C [96.8 ˚F].
7. As temperature increases, peripheral vasculature may dilate.
Maintain MAP greater than 80 mm Hg.
8. Monitor glucose every 2 hours during re-warming.
9. Once the patient has reached target temperature the console may
be placed on “Standby” and utilized for monitoring temperature for
up to a total of 72 hours.
10. If within the 72 hours that the catheter is in place the console may
be utilized in the fever control mode and set target temperature at
37.5. After 72 hours the tubing must be discarded. If the patient
becomes febrile after cooling catheter is removed, traditional water
circulating cooling blanket should be used to treat fever, which is
often unresponsive to acetaminophen.
11. Stop the 1:1 urine replacement if the patient is hemodynamically
stable and maintaining a urine output of at least 1cc/kg/hour or as
dictated by the patient’s condition.
b. Endovascular Cooling
1. Set the cooling catheter apparatus to 36.5 °C with a “controlled
rate” of 0.3 °C/hour.
CP/IB 2008
Draft updated 4/26/2010
2. Endovascular cooling in combination with antipyretics may be used
to ensure normothermia (strict avoidance of hyperthermia) over the
next 12 hours. The catheter should be removed within 72 total
hours of placement.
5. Supportive Care/Special Considerations
a. Resource personnel are available to help staff with questions related to
the protocol and for trouble shooting of the equipment. These resources
are not directly placing orders and all orders are to be discussed with the
critical care attending as usual and the appropriate cardiologist. The
attending of record is responsible for the management of the patient. In
the event there is a discrepancy in the care of the patient the medical
director of the respected unit should be notified.
b. Administer appropriate stress ulcer prophylaxis.
c. Deep venous thrombosis prophylaxis as appropriate.
d. Keep head of bed elevated at 30˚ to prevent aspiration by using reverse
trendelenberg) in order to prevent kinking of the catheter.
e. Patients should NOT have sedation holiday during MTH protocol.
f. Complete serial EKGs every 8 hours x 3, then daily.
g. Avoid bathing patient during hypothermic or rewarming period.
h. Lab Work: CMP, CBC, PT/PTT/INR, ABG, cardiac enzymes, lactate every
8 hours x 3, then daily.
i. If patient has not regained any neurological function at 72 hours after
initiation of MTH, consider evaluation for brain death (Refer to the policy
“Declaration of Death upon the Basis of Neurological Criteria”). Please
note there are reports of patients awakening after 72 hours due to slowed
metabolism of sedation medication, etc. Prognostication prior to 72 hours
is considered unreliable.
j. If burst or sz activity is noted on EEG, treatment with ativan, keppra,
depakote, lamictal, zonegran, or topamax, can be considered depending
upon the clinical situation although this commonly represents prior anoxic
neural injury and is poorly responsive to therapy.
k. Nutrition should be considered as soon as the patient becomes
normothermic.
l. MTH can inhibit CP450 metabolism; increase plasma concentration of
Midazolam, Propofol, and Fentanyl; and increase the duration of action of
Vecuronium. In animal studies, however, morphine’s potency and affinity
for mu receptors declined, requiring higher doses for desired analgesia2.
m. If appropriate or indicated the distal port of the catheter may be used to
transducer CVP (during hypothermia the CVP may be artificially elevated)
or a ScVO2 specimen.
n. Lacrilube should be applied to each eye every 8 hours and prn while
paralyzed.
o. Forehead pulse oximeter with a fingertip sensor may be inadequate, so
frequent ABG’s may be indicated.
p. Apply Prafo boots/high top sneakers while paralyzed to prevent foot drop.
6. Monitoring for Complications
a. Monitor patient for potential complications and document any of the
following for 72 hours from initiation of MTH.
CP/IB 2008
Draft updated 4/26/2010
1. Bleeding: any clinically significant bleeding requiring transfusion, or
hemoglobin concentration drop greater or equal to 2 g/dl.
2. Cardiac arrhythmia: any cardiac arrhythmia requiring treatment with an
anti-arrhythmic agent or cardioversion.
3. Infection: any new infection requiring initiation of antibiotic therapy.
4. Temperature overshoot: body temperature less than 32 ºC [89.6 ˚F] for
more than 1 hour in duration3.
7. Reasons for early discontinuation of MTH.
a. If the patient develops any of the below conditions thought to be related to
cooling, the cooling devices need to be discontinued immediately and the
patient will be allowed to passively re-warm.
1. Ventricular tachycardia or ventricular fibrillation.
2. Asystole.
3. Sustained SVT.
4. Refractory hypotension despite 2 vasopressors and not an intra-aortic
balloon pump (IABP) candidate. .
8. Performance Improvement
a. Each case will be reviewed as part of an ongoing process by
multidisciplinary Therapeutic Hypothermia working group.
9. Education:
a. Families and next of kin should be provided with education as
appropriate.
References:
1.
2.
3.
Giacino JT. Disorders of consciousness: differential diagnosis and
neuropathologic features. Semin Neurol. Jun 1997;17(2):105-111.
Tortorici MA, Kochanek PM, Poloyac SM. Effects of hypothermia on drug
disposition, metabolism, and response: A focus of hypothermia-mediated
alterations on the cytochrome P450 enzyme system. Crit Care Med. Sep
2007;35(9):2196-2204.
Merchant RM, Abella BS, Peberdy MA, et al. Therapeutic hypothermia after
cardiac arrest: unintentional overcooling is common using ice packs and
conventional cooling blankets. Crit Care Med. Dec 2006;34(12 Suppl):S490-494.
CP/IB 2008
Draft updated 4/26/2010