Download Highlights from the 2015 Recommendations for

Targeted Temperature
Management (TTM)
Nikhia Williams, RN, BSN, CCRN
• I have no conflicts of interest to declare.
What is Targeted Temperature
Management (TTM)?
• Targeted temperature management (TTM)
previously known as therapeutic hypothermia or
protective/induced hypothermia is active
treatment that tries to achieve and maintain a
specific body temperature in a person for a
specific duration of time in an effort to improve
health outcomes during recovery after a period
of stopped blood flow to the brain.
2005 American Heart Association
Guidelines for TTM
▫ Unconscious adult patients with return of spontaneous
circulation after out-of-hospital cardiac arrest should
be cooled to 32-34° C for 12-24 hours when initial
rhythm was ventricular fibrillation (VF) (class IIa)
▫ Similar therapy may be beneficial for patients with
non-VF arrest out-of-hospital or with in-hospital
arrest (class IIb)
▫ Hemodynamically stable patients with spontaneous
mild hypothermia (>33°C) after resuscitation from
cardiac arrest should not be actively rewarmed
Highlights from the 2015 Recommendations for
Post-Cardiac Arrest Care from the American
Heart Association include:
• Class I (strong) recommendations for:
▫ TTM to treat comatose post-cardiac arrest patients suffering Out of
Hospital VF/pulseless VT
▫ TTM to treat comatose post-cardiac arrest patients suffering nonVF/pulseless VT (‘non-shockable’) rhythms and In Hospital Cardiac
Arrest (stronger recommendation than the 2010 guidelines)
▫ Selection and maintenance of a constant temperature within the range
32 C and 36 C
• Class IIa (moderate) recommendation for TTM to be maintained for at least
24 hours after reaching target temperature
• Class IIb (weak) recommendation that it may be reasonable to actively
prevent fever in comatose patients
• Class III (moderate – no benefit) recommendation against routine prehospital cooling of patients after ROSC with the rapid infusion of cold
intravenous fluids.
http://www.med.upenn.edu/resuscitation/hypothermia/2015AHAGuidelinesUpdate.shtml
TTM 33 vs. 36 degrees?
• The 2015 AHA guidelines did not refer to a select
temperature, their guideline was to select and
maintain a constant temperature within the
range of 32 and 36 degrees Celsius
• Each institution will have their own guidelines
for the temperature selection. Please refer to
specific protocols/order sets.
TTM 33 vs. 36 degrees?
• Within OSF ministry, our TTM goal is 33
degrees for our cardiac arrest patients.
• In the stroke, traumatic brain injury, and other
neurological patients, the TTM goal is typically
36 degrees
• 36 degrees is also known as Normothermia
Further Discussion on TTM at 33
degrees
Who receives TTM?
• For our patients that suffered a cardiac arrest
(PEA, Asystole, Vtach, and Vfib) and achieved a
return of spontaneous circulation (ROSC) and
are not following commands are part of the
inclusion criteria.
• Each patient should be evaluated by the
appropriately trained providers to determine
whether or not TTM should be started.
How is TTM accomplished?
• Use of cooling devices
▫ Intravascular Devices
▫ Esophageal Devices
▫ Surface Devices
Intravascular TTM
Devices
• Currently, this device is
produced by Zoll.
• There are several types of
catheters which may require
additional training by the
provider placing them.
• External water regulation
device
Intravascular Cooling Device
Esophageal TTM
Devices
• Currently, this device is
produced by Advanced Cooling
Therapy.
• There are two types of
catheters that connect to two
different external water
regulation devices.
• Can be placed like an OG tube.
Surface TTM Devices
• Currently, there are several
surface TTM options.
• The first is the Stryker
Version. It includes wraps
that are placed on the patient
with an external water
regulation device.
• Can be placed by trained
provider.
Surface TTM Devices
• Another option is the Arctic
Sun TTM device.
• Pads are placed on the patients
and there is an external water
regulation device.
• Can be placed by a trained
provider.
Temperature Sources
• Esophageal
• Foley
• Rectal
How is TTM accomplished?
•
•
•
•
•
Cold Saline
Sedation
Paralytics
Counterwarming
EEG/BIS monitoring
Cold Saline
• Previously this may have been initiated in the field.
As of 2015 AHA Guidelines, there is a Class III
(moderate – no benefit) recommendation against
routine pre-hospital cooling of patients after
ROSC with the rapid infusion of cold intravenous
fluids.
• Cold Saline is now started in the ED or on the units
that TTM is performed on.
• Typically given for patients with a temperature of
greater than 35 degrees Celsius to obtain 33 degrees
quickly.
Sedation
• Pushes of pain medications and sedation prior to
infusions
• Fentanyl and Propofol
• Fentanyl and Versed
Shivering
• If the patient is shivering, then the whole
decrease of oxygen demands are counteracted.
• Shivering actually increases the oxygen demands
of the patient.
Bedside Shiver Assessment Scale
(BSAS)
• Tool utilized to measure patient shivering levels
• 0-None: No Shivering
• 1- Mild: Shivering localized to neck/thorax,
may be seen only as artifact on ECG or felt by
palpitation
• 2-Moderate-intermttent involvement of the
upper extremities +/- thorax
• 3-Severe: Generalized shivering or sustain
upper/lower extremity shivering
• http://ccforum.biomedcentral.com/articles/10.1186/cc11267
Paralytics
•
•
•
•
Maximize sedation prior to paralytic infusion
Train of Four prior to initiation
Pushes
Infusions
Counterwarming Techniques
• Warm Blankets/Towels to hands and feet
• Forced Warm Air Blanket
• Adjunctive Medications
▫ Tylenol/Acetaminophen
▫ Magnesium
EEG/BIS Monitoring
• EEG can be continuous. The institution will
need to have an Neurologist specially training in
EEG interpretation.
• BIS monitoring is another alternative to EEG
monitoring. BIS monitoring can give the
providers an indication of sedation level.
Durations of TTM phases
• Goal to reach target temperature is 4 hours.
▫
▫
▫
▫
Cold Saline
Sedation
TTM equipment
Counterwarming
Duration of TTM phases
• Once at goal temperature, the patient will
remain at that temperature for 24 hours.
• 2015 AHA Guidelines have a Class IIa
(moderate) recommendation for TTM to be
maintained for at least 24 hours after reaching
target temperature (LOE C-Expert Opinion).
Duration of TTM phases
• Rewarming will occur between 8-12 hours.
• Often times, the initiation of rewarming is a time
in which the patients are often unstable as they
are starting to vasodilate.
Post Rewarming
• Can continue therapy options for up to a total of
five days from cardiac arrest to prevent fever.
• AHA 2015 guidelines have a Class IIb (weak)
recommendation that it may be reasonable to
actively prevent fever in comatose patients (LOE
C-Limited Data).
Neuroprognostication
• The earliest time to prognosticate a poor
neurologic outcome using clinical examination
in patients treated with TTM is 72 hours after
cardiac arrest, but this time can be even longer
after cardiac arrest if the residual effect of
sedation or paralysis is suspected to confound
the clinical examination.
The future of TTM
• ECPR may be considered an alternative to
conventional CPR for select patients who have a
cardiac arrest and for whom the suspected
etiology of the cardiac arrest is potentially
reversible.
• Additional research opportunities are endless.
Questions?????
Resources
• http://ccforum.biomedcentral.com/articles/10.1
186/cc11267
• https://eccguidelines.heart.org/wpcontent/uploads/2015/10/2015-AHAGuidelines-Highlights-English.pdf
• http://www.med.upenn.edu/resuscitation/hypo
thermia/2015AHAGuidelinesUpdate.shtml