San
Francisco General Hospital Hypothermia after Cardiac Arrest Protocol
Inclusion
Criteria:
Exclusions:
1. Another reason to be comatose (e.g. convulsive
status epilepticus)
2. Pregnancy
3. A known terminal illness preceding
the arrest
4. Known severe pre-existing coagulopathy or active bleeding (relative exclusion, esp for patients on warfarin
anticoagulation at time of cardiac arrest)
5. No limit on duration of
resuscitation effort; however “down time” of less than 1 hour most desirable
6. Pre-existing DO NOT INTUBATE code
status and patient not intubated as part of resuscitation efforts
Protocol
(goal temperature 33O C to be achieved as soon as possible):
1. Patients should be enrolled as
quickly as possible. For out-of-hospital
arrests, ED attending will make decision to implement protocol. For in-hospital arrests, CCU resident in
charge of completed code will make decision.
2. Page on-call Neurology Consult
Resident at 443-NERV (6378) for immediate initial neurologic assessment prior
to pharmacologic paralysis. Do not
delay initiation of hypothermia pending this assessment.
3. Cooling methods: All patients should
have surface cooling begun immediately.
a. Place ice packs under the armpits,
next to the neck, on the torso and the limbs.
b. Consider 1 liter IV bolus of chilled
(4oC) NS.
c. Consider nasogastric
lavage with iced saline.
d. Two cooling blankets should be used,
one under and one over the patient.
4. Endovascular
cooling catheter (Innercool) may be placed at
discretion of Neurocritical Care Fellow (see supplement).
5. Temperature sensing Foley catheter
should be placed if available, otherwise rectal or tympanic temperatures should
be used (in that order).
6. Page the ICU Resident to
manage the ventilator and sedation in consultation with the Neurocritical Care
fellow.
7. The
ventilator humidifier should be turned off and a Heat Moisture Exchanger (HME)
should be used.
8. The room thermostat should be turned
off.
9. Administer midazolam
2-6 mg/hour and fentanyl 25-75 mcg/hour if sedation
needed. Propofol can be considered as an alternative
if patient is hemodynamically stable.
10. Once sedation is started, if patient
has significant shivering give vecuronium 0.1 mg/kg
bolus. If shivering continues then repeat vecuronium
boluses or start a drip of 1 mg/hour.
Titrate the drip 0-5 mg/hr to keep 1/4 twitches. Cisatracurium
may be alternative if renal failure present.
11. If seizures suspected, place patient
on continuous EEG monitoring.
12. Patients should be on insulin drip
if glucose > 140 mg/dl, daily aspirin, on pressors
and or nitrates to maintain blood pressure, and any anti-arrythmics
necessary.
13. Patients may receive other cardiac
interventions including systemic thrombolysis,
anticoagulation, and urgent cardiac cath
interventions as needed. Hypothermia
should proceed concurrent with these interventions.
14. Once the patient reaches 33O
C (bladder, rectal, or tympanic), keep patient at 33O C using
cooling catheter (if in place) or by removing ice packs and top cooling blanket
if necessary.
15. Begin rewarming
24 hours after the beginning of cooling (not 24 hours after target temperature
is reached). Patient should be slowly rewarmed to
37.0o C over 18-24 hours:
If cooling catheter is in place, then use console to control
rewarming. Otherwise allow slow passive rewarming.
i.
Turn
room thermostat up to normal.
ii.
Turn
on heater on ventilator.
iii.
Turn
off cooling blanket.
iv.
May
use regular blankets, but not warming blankets.
16. Paralysis, then sedation, may be
discontinued during or after rewarming, based on
shivering and other critical care issues.
Supplement to the San Francisco
General Hospital Hypothermia after Cardiac Arrest Protocol
Use of Intravascular
Cooling Catheter
Eligibility:
All patients meeting standard inclusion and exclusion
criteria for induced hypothermia following cardiac arrest are candidates for
endovascular cooling (use of the intravascular cooling catheter). Placement and management of these catheters
will be done under the supervision of the Neurocritical Care Fellow and/or
Attending (443-1414).
Exclusions:
Any condition that precludes
placement of a large-bore catheter (as large as 14 F) into the inferior vena
cava via a femoral vein. History of an IVC filter placement would be an
exclusion for this reason.
Protocol
for Endovascular Cooling:
·
Innercool Standard Console or Innercool Accutrol Console
All
items below are single-use and individually boxed:
·
Console-related Equipment
- Heat Exchange Coil
- Disposable
Circulating Pump
- Celsius Control
Circulating Set
(Works with either Innercool
Console, comes as kit with all three things)
·
Cooling Catheter Equipment
- Innercool
Catheter Introducer Kit (specific to 10.7 or 14 F catheter, but works with
either Standard catheter or Accutrol catheter)
- Innercool
Standard or Accutrol Catheter
- Use size 10.7 F for
patients <200 lbs, size 14 F for patients >200 lbs
·
Fluid for closed catheter loop
-
1L
or 500cc bag of Isolyte 7.4
·
Fluid that surrounds the cooling
coil when seated in the Console
-
Galden HT-135 perfluoropolyether
-
Only
needs to be ‘topped off’ if level is low.
Location of Equipment:
a)
The Innercool
Standard Console and Innercool Accutrol
Console are stored in Central Supply in the basement (in the room with the CVVH
machines); one set of console-related equipment (coil, pump, circulating set)
should be stored with the console.
b)
The various catheter permutations
(Standard 10.7F or 14F, Accutrol 10.7F or 14F)
c)
The Galden
HT-135 is in Central Supply.
a) For the Celsius Control catheter and
console, the Neurocritical Care Fellow and/or Attending with direct the nursing
staff to shut down the console, disconnect the console from the catheter
(connecting the two free ends of the catheter and the two free ends on the
console connection set), allowing for passive rewarming
to begin as per the standard protocol. The Neurocritical Care Fellow and/or
Attending will be responsible for removing the catheter.
b) For the Accutrol
catheter, the Console will be reprogrammed by the Neurocritical Care Fellow
and/or Attending or by a Neurology resident under the direction of the
Neurocritical Care Fellow and/or Attending to achieve a catheter-controlled rewarming. At the end of the rewarming
phase, once goal temperature is reached, the connection set can be disconnected
from the catheter (as in 9a above), and the Neurocritical Care Fellow and/or
Attending will remove the catheter.
UCSF Neurology Residents’ Tips for Hypothermia Protocol:
adapted from 2004 AAN “Brain Injury After Cardiac Arrest” course
Initial Assessment:
1.
Witnessed arrest?
2. Exact time of arrest
3. Initial rhythm
4. Duration of arrest
5. Duration of CPR required to
return circulation
6. Is patient comatose (no eye opening)?
Decision to Initiate
cooling:
Must call
the Neurocritical Fellow (443-1414 at SFGH, 443-NICU at Moffitt) to discuss
whether cooling is appropriate
Initial Exam:
Focus
on brain stem reflexes (pupils, corneals, oculocephalic reflex)
Focus
on best motor response (will need 24hour, 3day and 7day exams).
Initiating cooling:
1.
Start surface cooling measures immediately--DO NOT DELAY cooling for the sake
of head CT, cardiac cath etc. All these can be done concurrently.
2.
NICU fellow can place an intravenous cooling catheter
Surface cooling measures:
1. Cooling blankets/alcohol baths/ice
packs to all areas of the body
2. NG and bladder lavage
with ice cold saline
3. 1 liter bolus of cold (4o C)
normal saline
**Note: Main problem is not reaching target temp of 33o
C fast enough. Must go to bedside and assist with surface cooling measures. If
not using endovascular cooling, then be careful to avoid overshoot (< 32o
C).
Maintenance:
1.
Must absolutely eliminate shivering!
**sedation and neuromuscular blockade may
be needed, warm hands and feet,
2.
NPO for 48 hours
3.
Insulin gtt to keep glucose <140
4.
Replace K+ up to 3.4 only as rewarming causes rebound
hyperkalemia
5.
Maintain normal Mg++ levels
6.
Warm ABG to room temperature before reading
7.
Maintain CPP >60 and avoid hypotension
Rewarming:
1.
Begin 24 hours after cooling started.
2.
Controlled rewarming to 37oC over 18-24
hours if cooling catheter is in place.
3.
If no catheter, then PASSIVE rewarming back to 37o
C over 18-24 hours.
4.
Maintain goal temperature of 36.5o – 37o C for the first
24hours post cooling to avoid rebound hyperthermia (may need to maintain active
cooling with catheter or surface measures to achieve this).
Systemic complications:
1. Cardiac arrhythmia--particularly bradycardia. Vfib
unresponsive to cardioversion if overcooled.
2. Coagulopathy--platelet
dysfunction and PT/PTT increase
3. UTI/PNA from poor PMN function
4. Systemic Inflammatory Response Syndrome
if rewarming is too rapid
5. Metabolic abnl=
hypokalemia, hyperglycemia, pancreatitis,
ileus